Journal articles on the topic 'National Counselor Examination'

A national study conducted with the members of the American School Counselor Association (ASCA) database examined school counselors’ utilization of online technologies. The researchers also explored beliefs and practices and examined mitigating factors such as school counselors’ background, training, and experience. Training impacted counselors’ belief in the advantages of technology and their level of comfort. Females were significantly more likely to blur personal and professional boundaries irrespective of their training. The article discusses implications for school counselors.

This article reports on a study addressing student referral differences based on family structure, gender, and race in teacher-initiated contact to school counselors. Researchers used secondary data from the National Education Longitudinal Study. They used logit log linear analyses in this data analysis. Significant differences existed for all three variables–race, gender, and family structure–with teachers more likely to contact the school counselor when the student was male, African American, or living in a non-intact family structure.

This study describes the collaboration among a school counselor, a school counselor intern, an Advanced Placement Psychology teacher, and a counselor educator to improve African American access to Advanced Placement (AP) coursework and increase success on the AP Psychology national examination. The team initiated a process that recruited African American students into AP Psychology and supported them through group and individual counseling to create an achievement-minded cohort that emphasized peer relationships and academic success.

Abstract To carry out quality management of genetic counseling, it is important to know what genetic counseling exactly means and who the players are. The term “genetic counseling” was first defined by Reed in 1947. It describes a communication process dealing with genetic facts and psychosocial aspects and is an education process, too. It has always been understood in the context of individual and family problems, and is unrelated to eugenics. In 1975 the Ad Hoc Committee of the American Society of Human Genetics published a more detailed description. With the development of new diagnostic techniques and methods in human genetics, the requirements of genetic counseling and its contents changed. Today a genetic counselor has to apply diagnostic, predictive, susceptibility, pharmacogenetic, carrier, prenatal, and preimplantation testing, as well as genetic screening. The German Human Genetic Examination Act (Genetic Diagnosis Act – GenDG) and national and international associations recommend to embed genetic testing into genetic counseling. Based on experiences of the author, some examples of pitfalls in genetic counseling are illustrated, as there are so many individual situations and requests that it seems impossible to carry out quality management. Nevertheless, the Commission for Quality in Genetic Counseling and Clinical Genetics of the Professional Association of German Human Geneticists started a pilot ring trial in 2018 with a given counseling situation. The task was to write the human genetics comment with the help of a checklist containing all issues necessary. The evaluation was conducted with the help of a catalogue of criteria which had been established beforehand and a score adjusted to the individual situation. The first genuine pilot trial was launched in 2020. It represents a possibility for quality management in genetic counseling.

Test anxiety has long been an issue with students, parents and in schools on a global level. Many students are becoming overwhelmed with the increased demands placed on test preparation and test performance. Accountability measures have become a major priority, with school children enduring standardized testing annually from grades three through eight, and once more in high school. This article will explore the many facets of test anxiety, what some schools are doing to try to reduce the anxiety and interventions counselors can use in their work with students. Keywords: Test anxiety; schools; children; anxiety

This article describes the need for trained career development personnel to assist in a variety of settings. The professional role and training requirements in the United States and Australia show a marked similarity in recent government attention to the area and in the sequence and timing of initiatives. A disparity that exists between state provisions of training and expectations of standards is receiving attention from national government bodies and national professional associations. Professional bodies in both countries are currently developing national certification and accreditation guidelines and procedures, but the United States, with its tradition of training, supervision and examination, has moved much further along the accreditation path than Australia. Some of the major issues concerning the certification and accreditation of careers practitioners and examples of training and curriculum models are provided. The article provides a glimpse of future directions in the profession of career counselling.

AbstractThe present study investigated the relationship between selected personal determinants and examination cheating among Kenyan secondary school students. This study used a Sequential Explanatory design. The target population was 51,900 students in Kisumu County within 153 public secondary schools categorized as 2 National secondary schools, 21 extra county schools, and 130 county and sub-county schools. A simple random sampling technique was used to determine sample size which comprised of 380 respondents since the study was confined within specific ecological boundary which was public secondary schools. Data collection instruments included questionnaires, for general data collection from the respondents and in-depth interview schedules for one to one interview of respondents. The finding of the study shows that there was statistically significant positive correlation (r=.592, n=360, p<.05) between Personal determinants and overall perceived level of exams cheating. It is evident from the model that student personal characteristics accounted for 35.1%, as signified by coefficient R2= .351, of the variation in perceived level of examinations cheating among students in secondary schools. it is evident that gender made the highest (Beta=.467) contribution as personal determinant on explaining the dependent variable, when the variance explained by all other variables in the model was controlled for. Student self-esteem had the least effect (Beta=.048) on examinations cheating. However, all the personal determinants had statistically significant influence on examinations cheating among the secondary schools students. The calculated effect size (eta squared=.3514) indicate that there was quite a substantial amount of variance in level of examinations cheating caused by variability in the personal determinants of the students. This suggests that 35.1% of the variance in the perceived exams cheating was accounted for by the personal determinants of the secondary school students, when other variables were controlled. Teacher counselors to assess and identify those students at risk and change their perception on examination cheating due to low self-efficacy.

The high rates of depression, anxiety, suicide, and other mental health disorders among collegiate student-athletes have resulted in the need for appropriate mental health services. The National Collegiate Athletic Association (NCAA) has released a best practices guide for mental health in college sport that includes licensed psychologists (LP), licensed clinical social workers (LCSW), and licensed professional counselors (LPC) as competent to provide mental health services to student-athletes. However, an examination of the differences between these three licenses is absent from the literature. This essay offers an overview on these differences to clarify the purview of each license as there is confusion surrounding the different types of professionals that can provide mental health services. A detailed description of what is means to hold an LP, LCSW, and LPC distinction is provided, followed by a discussion of the difference between mental health licensure and certification as a certified mental performance consultant (CMPC). This will assist administrators, athletic administrators, and student-athletes in making informed decisions about mental health care.

PURPOSE Breast cancer (BC) is detected at late stages in sub-Saharan Africa. We piloted a BC early-detection program in Eswatini aimed at increasing breast health knowledge and clinical skills. We also aimed to determine the proportion of patients with breast abnormalities who completed referral to breast specialty clinics. METHODS Nurses and counselors from five human immunodeficiency virus and/or antiretroviral therapy clinics underwent training in BC and clinical breast examination (CBE). We compared knowledge and skill examinations completed before, immediately after, and 90 days after training. Nurses then screened female clinic patients ≥ 18 years for breast symptoms, examined those with symptoms, and referred women with CBE abnormalities to a surgeon or the national breast clinic. Consenting women were contacted at 30 and 60 days after screening to determine if they had completed referral. RESULTS In 2019, 44 nurses underwent training. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training knowledge examinations were 17.5 (16-19), 20 (19-21), and 20 (19-21), respectively. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training skills examinations were 10 (7-11), 23 (21.5-25), and 23 (22-24), respectively. Compared with pretraining scores, post-training scores were significantly improved ( P < .0001 for all comparisons). From June 2019 to April 2020, a total of 9,502 clinic patients were screened for breast symptoms: 150 (2%) underwent CBE, 93 (62%) were referred for further evaluation, and 88 (97%) were included in the study. Of those, 54 (61%) completed referral. Referral completion was not associated with age, employment, relationship status, or prior experiences related to BC. CONCLUSION The program's training curriculum improved breast health knowledge and clinical skills. Efforts are needed to improve patients' receipt of recommended evaluation for breast abnormalities.

The study aims to evaluating the impact of guidance and counseling services on the academic performance of students in some selected secondary schools in Sokoto metropolis. Causal-comparative (Ex-post facto) research design was adopted for this study. This study involves a total of 200 subjects comprising 5 principals, 25 class teachers, 10 teacher counselors, and 160 students from the five selected schools. Data were collected using the four sets of questionnaires. Data analysis was done using descriptive and inferential statistics. The finding revealed that eighty percent (80%) of the students responded that their academic performance was changed after receiving counseling services. Seventy-two percent (72%) of the class teachers perceived the level of students’ academic performance after counseling as good, while 20% perceived it very good and 8% rated it bad. Guidance and counseling services have positively influenced the academic performance of the students and should be strengthened to improve the students’ performance in national examinations.

Objective We aimed to determine the ocular manifestation and refractive error prevalences among people living with HIV (PLHIV) in Pune, India. Methods This cross-sectional study included HIV-infected adults attending a National AIDS Research Institute clinic. Ophthalmologic examination included visual acuity estimation, refraction, orthoptic evaluation, slit lamp and fundus examination, and photography. Results In total, 441 HIV-infected individuals were enrolled. The participants' median age was 44 (interquartile range 38–49) years and 227 (51.5%) were men. Refractive errors occurred in 132 (29.9%) individuals. Ocular manifestations were present in 93 (21.1%) participants and the most frequent was cataract in 59 (13.4%) participants. Multivariate logistic regression analysis showed that participants who were illiterate (adjusted odds ratio [AOR] 2.80, 95% confidence interval [CI] 1.47–5.33) and those aged greater than 40 years (AOR 5.59, 95% CI 2.69–11.61) were more likely to have ocular manifestations. The odds of having ocular manifestations were greater in participants with treatment substitution or changes (AOR 2.11, 95% CI 1.16–3.82). Conclusions Cataract and refractive errors were prevalent among PLHIV. PLHIV should be encouraged to have regular ophthalmic checkups. Individuals with lower education levels and older age should be counseled regarding eye care and timely reporting of ocular symptoms.

• Background Tobacco dependence is the leading preventable cause of death in the United States, yet healthcare professionals are not adequately educated on how to help patients break the deadly cycle of tobacco dependence. • Objective To assess the content and extent of tobacco education in the curricula of acute care nurse practitioner programs in the United States. • Methods A survey with 13 multiple-choice items was distributed to the coordinators of 72 acute care nurse practitioner programs. The survey was replicated and modified from previous research on tobacco dependence curricula in undergraduate medical education. • Results Fifty programs (83%) responded to the survey. Overall, during an entire course of study, 70% of the respondents reported that only between 1 and 3 hours of content on tobacco dependence was covered. Seventy-eight percent reported that students were not required to teach smoking-cessation techniques to patients, and 94% did not provide opportunities for students to be certified as smoking-cessation counselors. Sixty percent reported that the national guidelines for smoking cessation were not used as a curriculum reference for tobacco content. • Conclusions The majority of acute care nurse practitioner programs include brief tobacco education. More in-depth coverage is required to reduce tobacco dependence. Acute care nurse practitioners are in a prime position to intervene with tobacco dependence, especially when patients are recovering from life-threatening events. National recommendations for core tobacco curricula and inclusion of tobacco questions on board examinations should be developed and implemented.

One crime that often occurs in Indonesia is drug use. Protection of children in a national society is a benchmark of the nation's civilization, so it must be pursued in accordance with the abilities of the nation. The study was conducted by using an empirical juridical approach. The data used are primary data obtained by interview and secondary data obtained through literature studies. The results of the study are described as follows: As for the implementation of investigations against children involved in narcotics transactions in the jurisdiction of Payakumbuh Police conducted by investigators basically in accordance with the Criminal Procedural Code and Law Number 11 Year 2012 Concerning the Criminal Justice System that applies even though in its implementation it has not maximize due to some limitations. The rights granted to child as suspects are also given in the form of rights avoided from acts of violence, accompanied by legal counsel and social guidance, the right to express opinions, views freely, receive care and welfare, and the right to be treated equally, Obstacles arising in investigations of children involved in Narcotics transactions in the Payakumbuh Police jurisdiction, including the time to detain children is very limited, namely seven days and can be extended eight days so that investigators must be extra fast to be able to complete the case file, should conduct an examination at the BPOM Padang laboratory. It must be also delivered and picked up by investigators and wait for the results of BAPAS research on the child concerned, and the absence of special investigators for children.

Early research investigating the personality of college-aged student and professional musicians examined traits of music performers, composers, and music teachers. Subsequent research studies followed with examinations of personality in university music programs, several of which employed the Myers-Briggs Personality Inventory (MBTI). The prevalence of MBTI types has not been examined amongst the diversity of music programs currently offered in many universities. The purpose of this study was to examine the prevalence of MBTI psychological type of university music students ( N = 217) across six different music majors (i.e., Music Business, Music Composition, Music Education, Music Engineering, Music Performance, and Music Therapy). The MBTI mental function of Intuitive–Feeling was found to be highly over-represented in the total music sample as compared to national norms, while several other personality preferences significantly dominated or were sparse in the music majors. The findings extend the personality and music research literature and have practical implications for music educators, academic counsellors, college-aged music students, and students who are considering music as a study and career.

Objective This State of the Art Review aims (1) to define recent qualifications of otolaryngology resident applicants by focusing on United States Medical Licensing Examination (USMLE) scores, Alpha Omega Alpha (AOA) status, and research/publications and (2) to summarize the current literature regarding the relationship between these measures and performance in residency. Data Sources Electronic Residency Application Service, National Residency Matching Program, PubMed, Ovid, and GoogleScholar. Review Methods Electronic Residency Application Service and National Residency Matching Program data were analyzed to evaluate trends in applicant numbers and qualifications. Additionally, a literature search was performed with the aforementioned databases to identify relevant articles published in the past 5 years that examined USMLE Step 1 scores, AOA status, and research/publications. Conclusions Compared with other highly competitive fields over the past 3 years, the only specialty with decreasing applicant numbers is otolaryngology, with the rest remaining relatively stable or slightly increased. Additionally, USMLE Step 1 scores, AOA status, and research/publications do not reliably correlate with performance in residency. Implications for Practice The consistent decline in applications for otolaryngology residency is concerning and reflects a need for change in the current stereotype of the “ideal” otolaryngology applicant. This includes consideration of additional selection measures focusing on noncognitive and holistic qualities. Furthermore, otolaryngology faculty should counsel medical students that applying in otolaryngology is not “impossible” but rather a feasible and worthwhile endeavor.

Politiskās plānošanas dokumentos tiek atzīts, ka Latvijā samazinās juridiskās izglītības kvalitāte un tiesību zinātņu studiju programmu absolventiem ir vājas zināšanas un prasmes jurisprudencē. Lai paaugstinātu juridiskās izglītības kvalitāti, Latvijas Republikas Ministru kabinets 2015. gadā akceptēja rīkojumu par valsts vienotā jurista kvalifikācijas eksāmena ieviešanu 2021. gadā profesionālajās maģistrantūras studiju programmās “Tiesību zinātne”, vienlaikus augstākās izglītības sistēmā likvidējot profesionālās bakalaura studiju programmas un liedzot studējošajiem iespēju iegūt juriskonsulta kvalifikāciju. Augstākās juridiskās izglītības sistēma kopumā tiek pārveidota. Valsts vienotā jurista kvalifikācijas eksāmena ieviešana rada nepieciešamību pārveidot studiju procesu, veikt izmaiņas īstenotajos studiju kursos un papildināt prasības tiesību apakšnozarēs, kurās tiks pārbaudītas studējošo zināšanas vienotā eksāmenā. Political planning documents recognise that quality of legal education is decreasing in Latvia, graduates of law study programmes have poor knowledge and skills in jurisprudence. In order to increase the quality of legal education, the Cabinet of Ministers of the Republic of Latvia in 2015 accepts the order on the introduction of the State Unified Lawyer’s Qualification Exam in 2021 in the professional Master’s study programme “Law Science”. At the same time, the higher education system eliminates professional bachelor study programmes and prevents students from gaining legal counsel. The higher legal education system as a whole is transformed. The introduction of the State Jurisprudence Expert Examination determines the necessity to transform the study process, to make changes in the study courses to be implemented, to supplement the requirements in the sub-branches of law, where students’ knowledge in a single examination will be checked. Currently, it is too early to conclude whether the introduction of a single national lawyers’ qualification examination will increase the quality of legal education, and graduates of legal science study programmes will increase their knowledge and skills in jurisprudence.

The problem of poor performance of students in public secondary schools in the national examination continues unabated despite numerous efforts and resources put into education development. The study sought to determine the relationship between problem solving approach and academic performance and to establish gender differences in the problem solving approaches among secondary school students in Kakamega Municipality. Correlation research design was adopted for the study. Using stratified sampling, six schools consisting of one boys school, one girls school, three public co-educational schools and one private co-educational school were sampled. Proportionate and simple random sampling was used to select a total of 200 students comprising of 113 boys and 87 girls. Questionnaires, observation check lists and Focus Group discussions were used to collect data. Quantitative data collected in the field was analysed using descriptive and inferential statistics, while qualitative data from Focus Group Discussion was analysed qualitatively. The differences between groups on studied variables were tested using t-test while correlation was used to test the null hypothesises at a significance level of .05. There was no significant relationship between problem solving approaches and academic performance while gender had no affect on problem solving. It was recommended that counsellors and secondary school teachers should train students in positive problem solving skills and an ideal environment should be created for students to acquire positive problem solving skills.

Alice Muthoni Wahome, one of the few women elected Members of Parliament, 2013-2016. She won the seat in a male dominated race after three attempts. She was born in Muruka in Kandara, Murang’a County. She schooled in Karumu primary school, 1966-1973, Siakago Girls High School, 1973-1976, Ngandu Girls High School, 1977-1978 and The University of Nairobi 1980-1984.The study covers the post-colonial period from the late 1950s to 2016.Alice Muthoni is currently representing the people of Kandara as the member of parliament. The objectives of this study were to examine the life and times of Alice Muthoni Wahome, assess her formative years from her childhood through primary school, secondary school and university education, examine her life as a state counsel and her life in politics in the eras of Mwai Kibaki and Uhuru Kenyatta. The study was informed by Subaltern theory, the Liberal feminism theory and the Trait theory. Literature Review involved examination of biographies and autobiographies of Kenyan and world leaders. A few gender related works have also been reviewed. Data collection involved a thorough examination of primary and secondary information. The oral evidence was gathered through conducting interviews, observation and focus groups discussions with respondents drawn from Kandara constituency, the m.p herself and her colleagues in parliament. The respondents were selected through purposive sampling and snowballing. The secondary data was collected from Mount Kenya University Library and the Postmodern Library of Kenyatta University. These were supplemented with archival research at Kenya National Archives. The internet was also used to get more information. Descriptive survey design was used.

The novel COVID-19 has affected every aspect of our lives in tremendous and unimaginable ways. The systems impacted include healthcare, education, economy, employment, and social systems including children and families. It has also affected our political and legal systems including individual rights as well as national discourse and international travel and relations. The advent of this unique and extraordinary issue requires that professionals like social workers, doctors, counselors/therapists, and psychologists adapt their approaches, strategies, skills, services and interventions to better serve clients/patients and operate effectively in the new societal order. This article explores the effect and response to the COVID-19 Pandemic within the United States as well as in the global context and draw an analytical relationship between it and the ecosystems theory. Thus, using the conceptual framework of the ecosystems theory, I draw a relationship between human behavior and the social environment using anecdotal cases in the context of the COVID-19 pandemic. I content that the polarized reactions from certain groups of individuals in relation to the COVID-19 pandemic restrictions and mask mandates are because people are social beings and are inextricably impacted by their social and ecological environment as well as factors within this environment, and requires a special examination, understanding, knowledge, adaptation, and strategic approach. Finally, I recommend best practice intervention approaches to social workers who are interacting, intervening, and/or providing services to these unique clients to support healthy working relationships, and to facilitate a formidable needs assessment that leads to a successful and safe interaction and intervention.

Notwithstanding the acceptance of firearm identification by courts, the scientific community has been reluctant to recognise firearm identification as a reliable method of conclusively establishing a connection between a particular bullet and a particular gun. The National Institute of Justice (NIJ) in the United States (US) has categorised firearm identification as a discipline under forensic science, and forensic science has been described as a "fractured and burdened discipline". In addition, in 2009 the National Academy of Sciences (NAS) concluded that forensic science is broken. With regard to firearm identification, the NAS Report emphasised the need for sufficient studies to be done because this report regarded this type of evidence as unreliable and lacking repeatability. The President's Council of Advisors on Science and Technology (PCAST) Report, released in September 2016, came to a conclusion similar to that of the 2009 NAS Report with regard to forensic science evidence. With regard to firearm identification, the report asserted that firearm identification evidence still "falls short of the scientific criteria for foundational validity". It is disturbing that courts across the globe are using different types of forensic science without subjecting them to scrutiny so as to determine their reliability. In the light of this, reliability and validity have become important factors which demand attention in Anglo-American litigation, even in jurisdictions that do not have a formal reliability standard (such as England and Wales, and South Africa). This article shows the role of cross-examination in establishing the reliability of firearm expert evidence. It also focusses on the role that South African forensic practitioners, prosecutors, defence counsels and presiding officers can play in ensuring the reliability of firearm identification evidence

Background: Sexually transmitted infections (STIs) are a public health problem globally, but especially so in sub-Saharan Africa. They contribute significantly to the burden of disease in South Africa and are recognised as major contributors to the human immunodeficiency virus (HIV) epidemic, with other potential complications when not managed properly. First-line doctors play a critical role in the management of persons suffering from STIs, and need to comply with the national guidelines for STI management.Aim: To determine the knowledge, attitudes and practices of doctors working in Jubilee District Hospital, Metsweding region, Tshwane, regarding the STI syndromic management (SM) guidelines.Setting: Jubilee District Hospital in Tshwane North, Gauteng province, South Africa.Methods: A cross-sectional, descriptive study using a self-administered questionnaire was conducted.Results: Forty-three of the 50 doctors employed at the hospital participated in the study. Fourteen (32.6%) of the doctors were in the 36–40-year age group. Most of the doctors (36 or 83.7%) had only the basic bachelor’s degree, and only 4 (9.3%) attended additional STI training. Only 2 respondents (4.6%) had correct knowledge concerning management of male urethritis syndrome and 10 (23.3%) regarding management of genital ulcer syndrome. In compliance with the national SM guidelines for STIs, 22 (52.4%) of the doctors said they made a diagnosis of STIs using history and physical examination. Only 7 (16.7%) said they asked their patients during every consultation about the number of sexual partners, 21 (51.7%) said they always counsel/ screen patients with STIs for HIV infection, and only 4 (9.5%) said they always filled in partner notification slips after attending to the index patient with STIs. This study demonstrated a relationship between doctors’ knowledge of the SM guidelines for STIs and their age.Conclusion: Overall the knowledge and practices of doctors at Jubilee District Hospital were suboptimal, and training on the SM of STIs should be made available to address this. Management should introduce regular monitoring, evaluation and supportive services for the doctors regarding their management of STIs according to the guidelines.

PURPOSE Clinical breast examination (CBE) is one of the most common methods used for early detection of breast cancer in low- and middle-income countries. CBE alone is limited by lack of specificity and may result in unnecessary diagnostic procedures. We evaluated the feasibility of integrating CBE, fine-needle aspiration biopsy (FNAB), and rapid on-site evaluation (ROSE) in triaging palpable breast masses for specialized cancer care. MATERIALS AND METHODS An intensive breast cancer screening event was conducted at a national trade fair by a multidisciplinary team of care providers targeting a healthy population in Dar es Salaam, Tanzania. All adults age ≥ 18 years were invited to participate. CBE was performed by oncologists and/or pathologists. FNAB was performed by a pathologist on palpable masses that were then categorized as benign, indeterminate, or suspicious for malignancy or definitively malignant based on ROSE. RESULTS A total of 208 individuals (207 females, one male; median age, 36 years; range, 18-68 years) were screened. Most (90.8%, 189 of 208) had normal findings, whereas 7.2% (15 of 208), 1% (2 of 208), and 1% (2 of 208) had a palpable mass, breast pain, and nipple discharge, respectively. Two participants had lesions too small for palpation-guided biopsy and clinically consistent with fibroadenomas; the participants were counseled, and observation was recommended. FNAB was performed on 13 breast masses, with 9 of 13 (69%) categorized as benign and 4 of 13 (31%) suspicious for malignancy. Final cytopathologic review of referred patients confirmed one case to be breast adenocarcinoma, one was suggestive of fibroadenoma, and two showed inflammations. CONCLUSION Integration of CBE with ROSE and FNAB was feasible in a breast cancer screening program in Tanzania. In settings with constrained resources for cancer care, this may be an effective method for triaging patients with breast masses.

1594 Background: Risk-reducing salpingo-oophorectomy (RRSO) is the gold standard in surgical prophylaxis of pelvic high-grade serous carcinoma (HGSC) for women at risk of breast/ovarian cancer. Due to significant adverse effects of early oophorectomy, 20-30% of women delay or deny performing this operation. Recent data highlight the fallopian origin of most pelvic HGSC, especially its fimbrial part. Thus, we suggested a new two-step risk-reducing procedure: the radical fimbriectomy (RF) with delayed oophorectomy (DO) (Leblanc et al Gyn Oncol 2011), leading to the current RF/DO Phase 2 study. We present the definitive results on primary and secondary objectives of this trial. Methods: BRCA1/2 carriers or any women with a documented familial risk of breast/ovarian cancer were first counseled to perform a classical laparoscopic RRSO. If they denied, they were offered to enter the RF/DO study. All specimens were submitted to the SEE-FIM pathological protocol. Pathological data along with all intra- and 30-day and beyond post-operative adverse events were prospectively recorded. Follow-up consisted in an annual clinical breast and gynecological examination, with tumor markers and hormonal status assessment. Primary endpoint was the rate of pelvic serous carcinoma. Secondary endpoints were procedure morbidity, rates of tubal abnormalities, breast cancer, secondary oophorectomy. Results: From January 2012 to October 2014, 121 RF were performed: 120 by laparoscopy, 1 laparotomy (concurrent myomectomy). An occult neoplasia was found in 3 cases with 1 invasive HGSC. Intraoperative complications were two grade1 bleedings without transfusion with no grade ≥3 early post-operative or delayed complication. With a median follow-up of 5.3 years (0.2 -7.6), no patient developed any pelvic HGSC, 21 patients developed a breast cancer (3 de novo, 18 recurrences/contralateral.). 1 cancer-free BRCA1-mutated lady delivered safe twins, after an uneventful post-RF pregnancy obtained with assisted reproductive technology (ART). Overall, 29 women underwent DO (by choice: 12 or menopause: 17) resulting in grade 3b complication in 1 case, but no pathological abnormality. Conclusions: RF/DO appears as a safe, well tolerated and effective procedure in terms of occult neoplasia detection. A successful pregnancy with ART was possible after radical fimbriectomy. Longer follow-up and larger cohort are necessary to confirm its efficacy in terms of ovarian cancer prophylaxis. Clinical trial information: NCT01608074.

BackgroundHealth care providers who care for patients with CKD must be able to provide effective counseling about a kidney-friendly diet. Nutrition is underemphasized in medical curricula, and the kidney diet is one of the most challenging diets. We hypothesized that participation in an experiential educational program in kidney diet would result in improved knowledge of the underlying principles behind it and provide concrete examples of how to explain this diet to patients.MethodsThe first part of this study was a knowledge assessment administered to all US nephrology fellows during the 2020 National Board of Medical Examiners Nephrology In-Training Examination. We later opened the assessment to a broader, global audience via social media. Respondents included trainees, practicing nephrologists, dieticians, and other health professionals. Participants self-identified willingness to participate in the second part of the study, the Kidney Diet Challenge (KDC). The 5-day challenge included daily webinars by experts in nutrition. Daily surveys captured self-reported adherence to the diet. Social media was used to engage with participants. All participants received a follow-up knowledge assessment.ResultsAmong the nephrology fellows (n=317), the median pretest score was 2 out of 5 (40%) questions correct, and results did not differ by year of training (P=0.31). Of the participants (n=70) who completed the 5-day challenge and responded to the post-challenge survey, the distribution of the number of correct answers improved after the KDC (median [25th, 75th percentile]: 3 [2, 3] versus 3 [2, 4]; P<0.001). Statistics from our official hashtag for this study (#kidneydietchallenge) showed that we achieved 406,241 reaches and 1,004,799 impressions, with a total of 974 posts using this hashtag.ConclusionsThe KDC is an immersive, experiential educational tool that enabled a global population to learn how to counsel their patients better about adherence to a complex kidney diet.

Background: Early diagnosis and prompt treatment can save lives of the patients with bladder cancer. The confirmatory test for grade of the disease is histopathological examination after transurethral resection. But if the grade of the tumor can be predicted at the time of presentation from size and number of tumors seen by ultrasonographic imaging, clinician can counsel the patient beforehand and also arrange rapid treatment to save life. Objective: To assess the size and number of tumors as clinical predictors of histological grade of urothelial carcinoma of urinary bladder before first-time transurethral resection of the bladder tumor (TURBT). Methods: This cross-sectional study was conducted in the Department of Urology, National Institute of Kidney Diseases & Urology (NIKDU), Dhaka, Bangladesh from January 2020 to April 2020. Fifty patients were enrolled in this study. Size and number of the tumor was determined by preoperative ultrasonography of urinary bladder. Histopathological examination was used to determine the grade of the tumor after TURBT. Statistical analysis was performed using SPSS version 22.0. Results: Mean age of the study subjects was 52.04 ± 18.37 years within the range of 22–95 years. Males (56.0%) were predominant than females (44.0%). Male to female ratio was 1.27:1. Mean number of tumor was 1.28 ± 0.64 (1-3) and mean tumor size was 3.54 ± 1.47 cm (1-7). High grade tumor was 26 (52.0%) and low grade tumor was 24 (48.0%). There was no significant association of tumor grading with number of tumor in this study. High grade tumor was significantly higher among the study subjects with tumor size >3.5 cm. Area under curve (AUC) of tumor number and tumor size was 0.558 and 0.827 respectively in prediction of tumor grading. Sensitivity, specificity, PPV, NPV and accuracy of tumor number (at cut of value 3) was 15.4%, 95.8%, 80.0%, 51.1% and 54.0% respectively. Sensitivity, specificity, PPV, NPV and accuracy of tumor size (at cut of value 3.5 cm) was 90.5%, 76.3%, 80.9%, 87.9% and 83.7% respectively. Overall Sensitivity, specificity, PPV, NPV and accuracy of tumor size was better than tumor number in prediction of tumor grading. Conclusion: According to this study finding, it can be concluded that the grade of newly diagnosed bladder tumors can be predicted with high accuracy using tumor size

Abstract There is growing popularity and interest in very-low-carbohydrate (VLC) diets for a variety of established and perceived health benefits. While some impacts have been seen in cardiometabolic diseases such as diabetes, hypertension and short-term weight loss (particularly when paired with caloric restriction), other effects such as in energy levels, mood and sense of well-being are variable. In the extreme, these diets suggest restriction of dietary carbohydrates (CHO) to less than 20 grams daily and often encourage a compensatory increase in dietary fat to promote ketogenesis. There has been concern about the long-term effects of these changes, as well as unintended consequences of increased saturated fat intake. A minority of patients, such as in the case below, may experience exaggerated lipid changes, thought to be influenced by underlying metabolic and genetic factors. Meta-analyses have shown conflicting results of the effects of VLC diets on low density lipoprotein cholesterol (LDL-C) levels. A 63-year-old woman presented for outpatient consultation for markedly elevated LDL-C 524 mg/dL. The rest of her lipid panel was as follows: total cholesterol 637 mg/dL, triglycerides 152 mg/dL, HDL-C 83 mg/dL. She was asymptomatic. Record review of annual laboratory testing from her primary care physician revealed baseline LDL-C 114–134 mg/dL between 2012 and 2017. Her lipid panel in 2017 was as follows: total cholesterol 216 mg/dL, triglycerides 82 mg/dL, HDL-C 68 mg/dL, LDL-C 132 mg/dL. She described that in late 2017 she began a VLC diet for perceived metabolic benefits, and in the past year intensified CHO restriction to less than 15 grams daily. In 2018–2019, her LDL-C level increased to 303–316 mg/dL, and in 2020 to 524 mg/dL. She had no history of diabetes, liver or kidney disease, nephrotic syndrome, hypothyroidism or alcohol use. She took no prescribed medications. She reported over-the-counter use of magnesium and potassium. She denied use of any other supplements or herbal remedies. Her past medical history included osteoarthritis. Her family history included hyperlipidemia in her mother, and coronary artery disease in both parents with age of onset in their 70s. She was a lifelong non-smoker and did not drink alcohol. Her BMI was 21.5. On examination, she was normotensive, euthyroid-appearing, and had no stigmata of familial hypercholesterolemia. Other labs were grossly normal, including blood counts, comprehensive metabolic panel, thyroid function tests, hemoglobin A1c and urinalysis. She was counseled extensively regarding her laboratory results and concerns about her cardiovascular safety. This case demonstrates an exaggerated lipid response to a VLC diet, and supports the National Lipid Association scientific statement Class IIa recommendation to obtain baseline and follow-up lipid profiles in patients who follow such diets due to variation in lipid response.

Background: Success of a cervical cancer screening program is intrinsically linked with appropriate management of women detected positive on screening tests. While routine screening can be done in any setting, the follow-up care of screen positive women is linked with settings that are equipped with diagnostic and treatment facilities, and trained medical providers. In low resource settings, the major obstacles to deliver follow-up care are lack of adequate healthcare infrastructure and trained service providers at district or subdistrict levels. Aim: To assess feasibility of implementing community based interventions to increase uptake of follow-up care of screen positive women in a HPV detection based screening program conducted by Chittaranjan National Cancer Institute (CNCI), Kolkata. Strategy: A network of key stakeholders including government authorities and civil society organizations was developed to deliver continuum of care at the doorsteps of screen positive women. The infrastructure of government's primary health care delivery system was used to set up temporary clinics at district and subdistrict levels. The clinics were organized on prescheduled dates and times that were convenient to the women. Community health workers (CHWs) were trained in community mobilization strategies to increase uptake of follow-up services. All instruments, equipment and consumables required for providing follow-up services were carried to the clinics in a vehicle. Program: The CHWs played a key role in counseling and recalling the screen positive women. The temporary clinics were arranged in the government primary health centers. A team of trained doctors and paramedics provided the diagnostic and treatment services. Colposcopy was performed on all screen positive women using portable colposcopes and guided biopsies were taken as indicated. Women who were eligible for ablative treatment were counseled and treated in the same sitting. All women were advised yearly follow-up. Outcomes: A total of 43,325 women were screened by HC2 test during July 2010 to March 2015, and 2045 (4.7%) women were detected to be high-risk HPV positive. Compliance to first recall was good with 78.6% (1608/2045) of women undergoing diagnostic evaluation at field clinics. But overall compliance to at least one follow-up visit after 1 year was poor (23.2%). Follow-up compliance rate was higher in women who were diagnosed with CIN1 as compared with those with normal diagnosis ( P < 0.001). What was learned: Diagnostic and treatment services could be effectively organized in the community in convergence with existing healthcare delivery system. High compliance to initial diagnostic evaluation and treatment was achieved by making the services available close to the doorsteps of the women. The reasons for low compliance to yearly follow-up were lack of understanding of future cancer risk, unwilling to undergo speculum examination again, and lack of cooperation of spouse/family.

Abstract Abstract 4190 INTRODUCTION: Recurrent pregnancy loss (RPL) can affect up to 5% of couples who are trying to conceive. In addition to the mental anguish, miscarriages are accompanied by the physical component of pain with the potential need for hospitalization and medical or surgical intervention. While, the recommended evaluation of RPL includes an assessment of multiple variables, including disorders of thrombophilia, the definition of RPL remains vague. Because no explicit definitions exist for RPL, we undertook an analysis of patients referred to a large, tertiary care center specifically for the evaluation and treatment of RPL. METHODS: We utilized data from the Duke University site of the Thrombosis and Hemostasis Centers Research and Prevention Network established by the Division of Blood Disorders of the Centers for Disease Control and Prevention (CDC). Patients referred to Duke University with a diagnosis of RPL were followed prospectively and their data regarding the diagnostic evaluation, prescribed treatments, and subsequent maternal-fetal outcomes were recorded. Information from the initial intake included demographic data, reason for referral, number and sequence of pregnancy losses, thrombophilia assessment, as well as the additional recommendations. Results of clinical evaluations performed at Duke, including coagulation assays, autoimmunity testing, examination of uterine anatomy, and parental chromosomal analysis were recorded, as well as any prescribed treatments of the current/subsequent pregnancy. Where follow-up data was available, results of the current and subsequent maternal and fetal outcomes were noted. RESULTS: As of March 2010, 2566 participants were enrolled in the CDC Patient Registry at Duke University, of which 62 were referred specifically for RPL. We found that almost 30% of referred patients (18/62) had undergone no prior testing, whereas at least 25% of referred patients came with a diagnosis that could not be confirmed. The most common misdiagnosis was of a thrombophilic marker, particularly with low-titer anti-phospholipid antibodies. Our evaluation found no discernible cause for RPL in 38% (23/62) of the women referred; our most common identified factor was a thrombophilic disorder (32%, 20/62) (Table 1). We found that analysis of the uterine cavity and assessment of parental chromosomes was infrequently performed prior to referral. The most common treatment recommendation was low molecular weight heparin, followed by observation alone. For patients who subsequently became pregnant, an overwhelming majority of women had no adverse maternal outcomes (86%), and a 72% live birth rate was recorded. Fortunately, no maternal deaths were observed. CONCLUSION: Women with underlying thrombophilia who are interested in having a successful pregnancy can be effectively diagnosed, counseled, and treated. These results show that for women with RPL, a coordinated, multi-disciplinary approach can be beneficial to achieving a safe pregnancy and healthy baby. Furthermore, the CDC Thrombosis and Hemostasis Centers Research and Prevention Network is enrolling a broad and robust patient population with thrombotic disorders and provides a national registry for tracking and evaluating pregnancy outcomes. Disclosures: Metjian: Expert testimony: Consultancy; Quintiles: Speakers Bureau; Avila Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Sextortion (a portmanteau of “sexual” and “extortion”) is a relatively new phenomenon of sexual exploitation, which occurs when a person threatens another with the distribution of sexual content on the Internet, to obtain more pictures or videos, money, or have some other demand met. The current study examined how school counselors in Israel perceive the phenomenon of online sextortion. To this end, we conducted a qualitative study based on 20 semi-structured in-depth interviews with school counselors working in middle schools and high schools in Israel, who treated adolescent girls blackmailed over the Internet on sexual grounds. Findings indicate that the school counselors had difficulty in identifying and defining the cases they treated as instances of sextortion, and that in their view the harm was slight. Findings also indicate that school counselors associated the causes of sextortion with the victims and their backgrounds. We found differences between the Arab and secular and national-religious state education in the way Jewish counselors treated the victims and involved additional actors such as the victim’s parents and the police. This underscores the importance of providing educational staff with adequate knowledge and tools that are culturally suited to the victims.

Background Health care systems serve an essential role in identifying and treating individuals impacted by human trafficking. The Department of Veterans Affairs (VA) Veterans Health Administration recognizes that human trafficking is a public safety concern and has intentionally increased awareness of human trafficking and how it relates to Veteran care. In 2020, the VA National Social Work Program Office, Care Management and Social Work launched a national Human Trafficking Tiger Team to understand the impact of human trafficking within the Veteran community. Methods Initial Human Trafficking Tiger Team efforts focused on qualitative reviews of existing VA health care services data to identify trends and themes. A series of three trainings for VA staff including Social Workers, Licensed Marriage and Family Therapists (LMFT), Licensed Professional Counselors (LPC), Psychologists (PsyD/PhD), Registered Nurses (RN), and Certified Rehabilitation Counselors (CRC) were completed. A pre and post-test was administered to assess VA staff’s knowledge about human trafficking and the impact on the Veteran community. Results Upon examination of qualitative review of evidence, formal study is needed to develop programming to address human trafficking in the Veteran community. Discussion Further study is needed to understand the prevalence of human trafficking among the Veteran population. While the VA’s human trafficking initiatives are integral initial steps, additional research remains necessary to identify treatment needs and services gaps. Conclusion Human Trafficking Tiger Team Knowledge Needs Assessment trainings revealed that VA staff had contact with survivors of human trafficking, suspected victims, as well as traffickers. 38% of staff acknowledged missed opportunities to assess and intervene with potential trafficking victims. This revealed a clear need for standardized screening, protocols, and implementing routine training to Veterans impacted by human trafficking.

Abstract We aim to examine the relation of several folate forms (5-methyltetrahydrofolate (5-mTHF), unmetabolised folic acid (UMFA) and MeFox) with kidney function and albuminuria, which remained uncertain. The cross-sectional study was conducted in 18 757 participants from National Health and Nutrition Examination Survey 2011–2018. The kidney outcomes were reduced estimated glomerular filtration rate (eGFR) (<60 ml/min/1·73 m2), microalbuminuria (albumin:creatinine ratio (ACR) of 30–299 mg/g) and macroalbuminuria (ACR ≥ 300 mg/g). Overall, there were significant inverse associations between serum 5-mTHF and kidney outcomes with significant lower prevalence of reduced eGFR (OR, 0·71; 95 % CI: 0·57, 0·87) and macroalbuminuria (OR, 0·65; 95 % CI: 0·46, 0·91) in participants in quartiles 3–4 (v. quartiles 1–2; both Pfor trend across quartiles <0·05). In contrast, there were significant positive relationship between serum UMFA and kidney outcomes with significant higher prevalence of reduced eGFR in participants in quartiles 2–4 (v. quartile 1; OR, 2·12; 95 % CI: 1·45, 3·12; Pfor trend <0·001) and higher prevalence of macroalbuminuria in participants in quartile 4 (v. quartiles 1–3; OR, 1·46; 95 % CI: 1·06, 2·01; Pfor trend <0·001). However, there was no significant associations of 5-mTHF and UMFA with microalbuminuria. In addition, there were significant positive relationships of serum MeFox with reduced eGFR, microalbuminuria and macroalbuminuria (all Pfor trend <0·01). In conclusion, higher 5-mTHF level, along with lower UMFA and MeFox level, was associated with lower prevalence of kidney outcomes, which may help counsel future clinical trials and nutritional guidelines regarding the folate supplement.

AbstractWhile the principles of procedural fairness apply in anti-doping disputes pursuant to Article 8 of the Word Anti-Doping Code, 2021 (the Code), there has been limited research assessing whether due process requirements are applied consistently by national anti-doping tribunals. This paper investigates the extent to which the procedural requirements set out under the Code are followed in practice, with a focus on India, New Zealand and Canada, facilitating comparison between developed and developing jurisdictions. By providing an evidence-based examination of first instance anti-doping procedures, this study confirms existing theories on the overall lack of harmonization in anti-doping procedures. We undertook a frequency analysis on the full-text awards handed down by first instance anti-doping tribunals in the comparative jurisdictions and the findings highlight inconsistent application of timeliness requirements and access to legal representation. Critically, in India, disputes take significantly longer to be resolved than in Canada and New Zealand, while far fewer Indian athletes are represented by legal counsel. In all jurisdictions, athletes who were represented by counsel were more likely to see a reduction in their sanctions. The study provides empirical evidence of systemic issues associated with timeliness and access to justice in anti-doping tribunals across jurisdictions and reinforces the need to focus on capacity building and enforcement of procedural safeguards, especially in developing countries. Practical recommendations include strategies to better achieve compliance and harmonization in protecting the procedural rights of athletes, particularly those athletes affected by the current application of the Code where cultural and socio-economic barriers may exacerbate procedural issues.

Cardiovascular diseases are an emerging cause of morbidity and mortality in India. India produces less than 150 cardiologists annually leading to a gap between the need and availability of trained professionals. Three years cardiology training programme is available for post graduate doctors in conventional medical education system. Majority of the people living in rural/small town/district town of the country do not have any access to cardiac care because trained cardiologists are mostly concentrated in the metro or capital cities. To address this issue Indira Gandhi National Open University has designed and developed a two-year full time training programme in the area of non-invasive cardiology named Post Graduate Diploma in Clinical Cardiology for medical graduates which is being offered through the open and distance learning mode. The objective of the programme is to train large number of medical graduates effectively to enable early recognition, management and prevention of common cardiovascular diseases. Learners have been given opportunity to train in different departments and posted in various areas like management of common cardiovascular diseases (6 months), ECG and Stress Testing (3 months), Echocardiography (3 months), ICU/CCU management (6 months), Paediatrics Cardiology (3 months), preventive cardiology (3 months) in this programme. Self learning materials, 33 video programmes (1260 minutes) and monthly live interactive teleconference (90 minutes) has been incorporated in this programme. Beside these, 50 theory counselling sessions, 25 guest lectures, seminars, journal club and case discussion has been taken care in every training center. Hands on skills training is provided to every learner as prescribed in this programme. The 72 credits programme is divided into 7 theory and 6 practical courses. Students need to pass in each course independently both in internal examination and term end examination. Minimum teacher-student ratio has been maintained strictly in both training and term end practical examination. The top most cardiac institutes/hospitals across the country have been identified as training centers as per the norms of the University. This programme has begun with 116 students in 16 training centers in 2006. 443 students have been enrolled in 67 training centres in 2013. More than 320 cardiologists are involved as academic counselors in this training programme. A total 1006 candidates have successfully completed their training and a many of them are providing services in small or district town of the country.

Abstract Background Puerperal sepsis is a genital tract infection that can occur from amniotic fluid rupture to six weeks after birth. Maternal complication associated with puerperal sepsis includes prolonged hospital stay, septicemia, disseminated intravascular coagulation, pelvic inflammatory disease, infertility, and death. Even though, puerperal sepsis is the fourth leading cause of maternal morbidity and mortality in Ethiopia the overall prevalence of puerperal sepsis and its associated factors are not studied at the national stage. As a result, this systematic review and meta-analysis bring out the pooled prevalence of puerperal sepsis and its associated factors in Ethiopia. Methods A variety of data sources such as Pub Med, Web of Science, Science Direct, Embase, Google Scholar, HINARI, and Ethiopian universities online repositories were searched to identify the primary studies which were used for this systematic review and meta-analysis. The article search was conducted from February10/2021-March 10/2021. The quality of the selected primary studies was assessed using the Newcastle - Ottawa quality assessment Scale (NOS). Data extraction was done with Microsoft Excel and then exported to STATA 11 version statistical software for analysis. The Cochran (Q-test) and I2 test statistics were used to assess the heterogeneity of the studies. Publication bias was evaluated by the eggers regression test. Subgroup analysis was performed with region and sample size category. Result In this review, a total of 2222 respondents were involved from seven studies. The pooled prevalence of puerperal sepsis was 14.811% (95%CI; 8.46: 21.16; I2 = 94.2, P ≤ 0.001). Cesarean section delivery (CSD) (OR = 3.26, 95%CI: 1.90, 5.61), membrane rupture≥24 h (OR = 4.04, 95%CI: 2.54, 6.42), being multiparous mother (OR = 3.99, 95%CI: 1.82, 8.78), vaginal examination≥5 times (OR = 3.15, 95%CI: 1.17, 8.52), and anemia (OR = 5.68, 95%CI: 4.38, 7.36) were factors significantly associated with puerperal sepsis. Conclusion The prevalence of puerperal sepsis was high in Ethiopia. CSD, membrane rupture≥24 h, being multiparous mother, vaginal examination≥5, and anemia were factors associated with puerperal sepsis. Appropriate standard infection prevention techniques during CSD shall be practiced to reduce the maternal burden of puerperal sepsis. The unnecessary vaginal examination should be discouraged during the intrapartum period. Besides this, routine Iron sulfate supplementation and counsel on iron reach foods during ante partum and postpartum shall be considered for all mothers.

Abstract Background Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for “not smoking now.” Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure. Objective To examine predictors of tobacco use and exposure among self-reported former smokers eligible for LCS. Design Cross-sectional study using the 2013–2018 National Health and Nutrition Examination Survey. Participants Former smokers eligible for LCS (n = 472). Main Measures Recent tobacco use was defined as reported tobacco use in the past 5 days or a cotinine level above the race/ethnic cut points for tobacco use. Recent tobacco exposure was measured among former smokers without recent tobacco use and defined as having a cotinine level above 0.05 ng/mL. Key Results One in five former smokers eligible for LCS, totaling 1,416,485 adults, had recent tobacco use (21.4%, 95% confidence interval (CI) 15.8%, 27.0%), with about a third each using cigarettes, e-cigarettes, or other tobacco products. Among former smokers without recent tobacco use, over half (53.0%, 95% CI: 44.6%, 61.4%) had cotinine levels indicating recent tobacco exposure. Certain subgroups had higher percentages for tobacco use or exposure, especially those having quit within the past 3 years or living with a household smoker. Conclusions Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million “former smokers” eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of “passive smokers” is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.

Abstract Background Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for “not smoking now.” Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure. Objective To examine predictors of tobacco use and exposure among self-reported former smokers eligible for LCS. Design Cross-sectional study using the 2013–2018 National Health and Nutrition Examination Survey. Participants Former smokers eligible for LCS (n = 472). Main Measures Recent tobacco use was defined as reported tobacco use in the past 5 days or a cotinine level above the race/ethnic cut points for tobacco use. Recent tobacco exposure was measured among former smokers without recent tobacco use and defined as having a cotinine level above 0.05 ng/mL. Key Results One in five former smokers eligible for LCS, totaling 1,416,485 adults, had recent tobacco use (21.4%, 95% confidence interval (CI) 15.8%, 27.0%), with about a third each using cigarettes, e-cigarettes, or other tobacco products. Among former smokers without recent tobacco use, over half (53.0%, 95% CI: 44.6%, 61.4%) had cotinine levels indicating recent tobacco exposure. Certain subgroups had higher percentages for tobacco use or exposure, especially those having quit within the past 3 years or living with a household smoker. Conclusions Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million “former smokers” eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of “passive smokers” is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.

Abstract Introduction Pre-treatment risk and prognostic groups are the cornerstone for deciding management in non-metastatic prostate cancer. All however, were developed in the pre-MRI era. Here we compared categorisation of cancers using either only clinical parameters or with MRI enhanced information in men referred for suspected prostate cancer from an unscreened population. Patient and methods Data from men referred from primary care to our diagnostic service and with both clinical (digital rectal examination [DRE] and systematic biopsies) and MRI enhanced attributes (MRI stage and combined systematic/targeted biopsies) were used for this study. Clinical vs MRI data were contrasted for clinico-pathological and risk group re-distribution using the European Association of Urology (EAU), American Urological Association (AUA) and UK National Institute for Health Care Excellence (NICE) Cambridge Prognostic Group (CPG) models. Differences were retrofitted to a population cohort with long-term prostate cancer mortality (PCM) outcomes to simulate impact on model performance. We further contrasted individualised overall survival (OS) predictions using the Predict Prostate algorithm. Results Data from 370 men were included (median age 66y). Pre-biopsy MRI stage reassignments occurred in 7.8% (versus DRE). Image-guided biopsies increased Grade Group 2 and ≥ Grade Group 3 assignments in 2.7% and 2.9% respectively. The main change in risk groups was more high-risk cancers (6.2% increase in the EAU and AUA system, 4.3% increase in CPG4 and 1.9% CPG5). When extrapolated to a historical population-based cohort (n = 10,139) the redistribution resulted in generally lower concordance indices for PCM. The 5-tier NICE-CPG system outperformed the 4-tier AUA and 3-tier EAU models (C Index 0.70 versus 0.65 and 0.64). Using an individualised prognostic model, changes in predicted OS were small (median difference 1% and 2% at 10- and 15-years’ respectively). Similarly, estimated treatment survival benefit changes were minimal (1% at both 10- and 15-years’ time frame). Conclusion MRI guided diagnostics does change pre-treatment risk groups assignments but the overall prognostic impact appears modest in men referred from unscreened populations. Particularly, when using more granular tiers or individualised prognostic models. Existing risk and prognostic models can continue to be used to counsel men about treatment option until long term survival outcomes are available.

In light of an ongoing debate over the authorship of the Redfern address (was it then Prime Minister Paul Keating or his speechwriter, Don Watson, who was responsible for this historic piece?), the authors of this article consider notions of ownership, authorship, and acknowledgement as they relate to the crafting, delivery, and reception of historical political speeches. There is focus, too, on the often-remarkable partnership that evolves between speechwriters and those who deliver the work. We argue that by drawing on the expertise of an artist or—in the case of the article at hand—speechwriter, collaboration facilitates the ‘translation’ of the politician’s or patron’s vision into a delivered reality. The article therefore proposes that while a speech, perhaps like a commissioned painting or sculpture, may be understood as the product of a highly synergistic collaboration between patron and producer, the power-bearer nonetheless retains essential ‘ownership’ of the material. This, we argue, is something other than the process of authorship adumbrated above. Leaving aside, for the present, the question of ownership, the context in which a speech is written and given may well intensify questions of authorship: the more politically significant or charged the context, the greater the potential impact of a speech and the more at stake in terms of its authorship. In addition to its focus on the latter, this article therefore also reflects on the considerable cultural resonance of the speech in question and, in so doing, assesses its significant impact on Australian reconciliation discourse. In arriving at our conclusions, we employ a method assemblage approach including analogy, comparison, historical reference, and interview. Comprising a range of investigative modalities such as those employed by us, John Law argues that a “method assemblage” is essentially a triangulated form of primary and secondary research facilitating the interrogation of social phenomena that do not easily yield to more traditional modes of research (Law 7). The approach is all the more relevant to this article since through it an assessment of the speech’s historical significance may be made. In particular, this article extensively compares the collaboration between Keating and Watson to that of United States President John F. Kennedy and Special Counsel and speechwriter Ted Sorensen. As the article reveals, this collaboration produced a number of Kennedy’s historic speeches and was mutually acknowledged as a particularly important relationship. Moreover, because both Sorensen and Watson were also key advisers to the leaders of their respective nations, the comparison is doubly fertile.On 10 December 1992 then Prime Minister Paul Keating launched the International Year of the World’s Indigenous People by delivering an address now recognised as a landmark in Australian, and even global, oratory. Alan Whiticker, for instance, includes the address in his Speeches That Shaped the Modern World. Following brief instruction from Keating (who was scheduled to give two orations on 10 December), the Prime Minister’s speechwriter and adviser, Don Watson, crafted the speech over the course of one evening. The oration that ensued was history-making: Keating became the first of all who held his office to declare that non-Indigenous Australians had dispossessed Aboriginal people; an unequivocal admission in which the Prime Minister confessed: “we committed the murders” (qtd. in Whiticker 331). The impact of this cannot be overstated. A personal interview with Jennifer Beale, an Indigenous Australian who was among the audience on that historic day, reveals the enormous significance of the address:I felt the mood of the crowd changed … when Keating said “we took the traditional lands” … . “we committed [the murders]” … [pauses] … I was so amazed to be standing there hearing a Prime Minister saying that… And I felt this sort of wave go over the crowd and they started actually paying attention… I’d never in my life heard … anyone say it like that: we did this, to you… (personal communication, 15 Dec. 2016)Later in the interview, when recalling a conversation in the Channel Seven newsroom where she formerly worked, Beale recalls a senior reporter saying that, with respect to Aboriginal history, there had been a ‘conservative cover up.’ Given the broader context (her being interviewed by the present authors about the Redfern Address) Beale’s response to that exchange is particularly poignant: “…it’s very rare that I have had these experiences in my life where I have been … [pauses at length] validated… by non-Aboriginal people” (op. cit.).The speech, then, is a crucial bookend in Australian reconciliation discourse, particularly as an admission of egregious wrongdoing to be addressed (Foye). The responding historical bookend is, of course, Kevin Rudd’s 2008 ‘Apology to the Stolen Generations’. Forming the focal point of the article at hand, the Redfern Address is significant for another reason: that is, as the source of a now historical controversy and very public (and very bitter) falling out between politician and speechwriter.Following the publication of Watson’s memoir Recollections of a Bleeding Heart, Keating denounced the former as having broken an unwritten contract that stipulates the speechwriter has the honour of ‘participating in the endeavour and the power in return for anonymity and confidentiality’ (Keating). In an opinion piece appearing in the Sydney Morning Herald, Keating argued that this implied contract is central to the speech-writing process:This is how political speeches are written, when the rapid business of government demands mass writing. A frequency of speeches that cannot be individually scripted by the political figure or leader giving them… After a pre-draft conference on a speech—canvassing the kind of things I thought we should say and include—unless the actual writing was off the beam, I would give the speech more or less off the printer… All of this only becomes an issue when the speechwriter steps from anonymity to claim particular speeches or words given to a leader or prime minister in the privacy of the workspace. Watson has done this. (Keating)Upon the release of After Words, a collection of Keating’s post-Prime Ministerial speeches, senior writer for The Australian, George Megalogenis opined that the book served to further Keating’s argument: “Take note, Don Watson; Keating is saying, ‘I can write’” (30). According to Phillip Adams, Keating once bluntly declared “I was in public life for twenty years without Don Watson and did pretty well” (154). On the subject of the partnership’s best-known speech, Keating claims that while Watson no doubt shared the sentiments invoked in the Redfern Address, “in the end, the vector force of the power and what to do with it could only come from me” (Keating).For his part, Watson has challenged Keating’s claim to being the rightfully acknowledged author of the Redfern Address. In an appearance on the ABC’s Q&A he asserted authorship of the material, listing other famous historical exponents of his profession who had taken credit for their place at the wheel of government: “I suppose I could say that while I was there, really I was responsible for the window boxes in Parliament House but, actually, I was writing speeches as speechwriters do; as Peggy Noonan did for Ronald Reagan; as Graham Freudenberg did for three or four Prime Ministers, and so on…” (Watson). Moreover, as Watson has suggested, a number of prominent speechwriters have gone on to take credit for their work in written memoirs. In an opinion piece in The Australian, Denis Glover observes that: “great speechwriters always write such books and have the good sense to wait until the theatre has closed, as Watson did.” A notable example of this after-the-era approach is Ted Sorensen’s Counselor in which the author nonetheless remains extraordinarily humble—observing that reticence, or ‘a passion for anonymity’, should characterise the posture of the Presidential speechwriter (131).In Counselor, Sorensen discusses his role as collaborator with Kennedy—likening the relationship between political actor and speechwriter to that between master and apprentice (130). He further observes that, like an apprentice, a speechwriter eventually learns to “[imitate] the style of the master, ultimately assisting him in the execution of the final work of art” (op. cit., 130-131). Unlike Watson’s claim to be the ‘speechwriter’—a ‘master’, of sorts—Sorensen more modestly declares that: “for eleven years, I was an apprentice” (op. cit., 131). At some length Sorensen focuses on this matter of anonymity, and the need to “minimize” his role (op. cit.). Reminiscent of the “unwritten contract” (see above) that Keating declares broken by Watson, Sorensen argues that his “reticence was [and is] the result of an implicit promise that [he] vowed never to break…” (op. cit.). In implying that the ownership of the speeches to which he contributed properly belongs to his President, Sorensen goes on to state that “Kennedy did deeply believe everything I helped write for him, because my writing came from my knowledge of his beliefs” (op. cit. 132). As Herbert Goldhamer observes in The Adviser, this knowing of a leader’s mind is central to the advisory function: “At times the adviser may facilitate the leader’s inner dialogue…” (15). The point is made again in Sorensen’s discussion of his role in the writing of Kennedy’s Profiles in Courage. In response to a charge that he [Sorensen] had ghost-written the book, Sorensen confessed that he might have privately boasted of having written much of it. (op. cit., 150) But he then goes on to observe that “the book’s concept was his [Kennedy’s], and that the selection of stories was his.” (op. cit.). “Like JFK’s speeches”, Sorensen continues, “Profiles in Courage was a collaboration…” (op. cit.).Later in Counselor, when discussing Kennedy’s inaugural address, it is interesting to note that Sorensen is somewhat less modest about the question of authorship. While the speech was and is ‘owned’ by Kennedy (the President requested its crafting, received it, edited the final product many times, and—with considerable aplomb—delivered it in the cold midday air of 20 January 1961), when discussing the authorship of the text Sorensen refers to the work of Thurston Clarke and Dick Tofel who independently conclude that the speech was a collaborative effort (op. cit. 227). Sorensen notes that while Clarke emphasised the President’s role and Tofel emphasised his own, the matter of who was principal craftsman will—and indeed should—remain forever clouded. To ensure that it will permanently remain so, following a discussion with Kennedy’s widow in 1965, Sorensen destroyed the preliminary manuscript. And, when pressed about the similarities between it and the final product (which he insists was revised many times by the President), he claims not to recall (op. cit. 227). Interestingly, Robert Dallek argues that while ‘suggestions of what to say came from many sources’, ‘the final version [of the speech] came from Kennedy’s hand’ (324). What history does confirm is that both Kennedy and Sorensen saw their work as fundamentally collaborative. Arthur Schlesinger Jr. records Kennedy’s words: “Ted is indispensable to me” (63). In the same volume, Schlesinger observes that the relationship between Sorensen and Kennedy was ‘special’ and that Sorensen felt himself to have a unique facility to know [Kennedy’s] mind and to ‘reproduce his idiom’ (op.cit.). Sorensen himself makes the point that his close friendship with the President made possible the success of the collaboration, and that this “could not later be replicated with someone else with whom [he] did not have that same relationship” (131). He refers, of course, to Lyndon Johnson. Kennedy’s choice of advisers (including Sorensen as Special Counsel) was, then, crucial—although he never ceded to Sorensen sole responsibility for all speechwriting. Indeed, as we shortly discuss, at critical junctures the President involved others (including Schlesinger, Richard Goodwin, and Myer Feldman) in the process of speech-craft and, on delivery day, sometimes departed from the scripts proffered.As was the case with Keating’s, creative tension characterised Kennedy’s administration. Schlesinger Jr. notes that it was an approach practiced early, in Kennedy’s strategy of keeping separate his groups of friends (71). During his Presidency, this fostering of creative tension extended to the drafting of speeches. In a special issue of Time, David von Drehle notes that the ‘Peace’ speech given 10 June 1963 was “prepared by a tight circle of advisers” (97). Still, even here, Sorensen’s role remained pivotal. One of those who worked on that speech (commonly regarded as Kennedy’s finest) was William Forster, Director of the Arms Control and Disarmament Agency. As indicated by the conditional “I think” in “Ted Sorensen, I think, sat up all night…”, Forster somewhat reluctantly concedes that while a group was involved, Sorensen’s contribution was central: “[Sorensen], with his remarkable ability to polish and write, was able to send each of us and the President the final draft about six or seven in the morning…” (op. cit.).In most cases, however, it fell on Sorensen alone to craft the President’s speeches. While Sorenson’s mind surely ‘rolled in unison’ with Kennedy’s (Schlesinger Jr. 597), and while Sorensen’s words dominated the texts, the President would nonetheless annotate scripts, excising redundant material and adding sentences. In the case of less formal orations, the President was capable of all but abandoning the script (a notable example was his October 1961 oration to mark the publication of the first four volumes of the John Quincy Adams papers) but for orations of national or international significance there remained a sense of careful collaboration between Kennedy and Sorensen. Yet, even in such cases, the President’s sense of occasion sometimes encouraged him to set aside his notes. As Arthur Schlesinger Jr. observes, Kennedy had an instinctive feel for language and often “spoke extemporaneously” (op. cit.). The most memorable example, of course, is the 1961 speech in Berlin where Kennedy (appalled by the erection of the Berlin Wall, and angry over the East’s churlish covering of the Brandenburg Gate) went “off-script and into dangerous diplomatic waters” (Tubridy 85). But the risky departure paid off in the form of a TKO against Chairman Khrushchev. In late 1960, following two independent phone calls concerning the incarceration of Martin Luther King, Kennedy had remarked to John Galbraith that “the best strategies are always accidental”—an approach that appears to have found its way into his formal rhetoric (Schlesinger Jr. 67).Ryan Tubridy, author of JFK in Ireland, observes that “while the original draft of the Berlin Wall speech had been geared to a sense of appeasement that acknowledged the Wall’s presence as something the West might have to accept, the ad libs suggested otherwise” (85). Referencing Arthur Schlesinger Jr.’s account of the delivery, Tubridy notes that the President’s aides observed the orator’s rising emotion—especially when departing from the script as written:There are some who say that Communism is the way of the future. Let them come to Berlin. And there are some who say in Europe and elsewhere we can work with the Communists. Let them come to Berlin … Freedom has many difficulties and democracy is not perfect, but we have never had to put up a wall to keep our people in.That the speech defined Kennedy’s presidency even more than did his inaugural address is widely agreed, and the President’s assertion “Ich bin ein Berliner” is one that has lived on now for over fifty years. The phrase was not part of the original script, but an addition included at the President’s request by Kennedy’s translator Robert Lochner.While this phrase and the various additional departures from the original script ‘make’ the speech, they are nonetheless part of a collaborative whole the nature of which we adumbrate above. Furthermore, it is a mark of the collaboration between speechwriter and speech-giver that on Air Force One, as they flew from West Germany to Ireland, Kennedy told Sorensen: “We’ll never have another day like this as long as we live” (op. cit. 88; Dallek 625). The speech, then, was a remarkable joint enterprise—and (at least privately) was acknowledged as such.It seems unlikely that Keating will ever (even semi-publicly) acknowledge the tremendous importance of Watson to his Prime Ministership. There seems not to have been a ‘Don is indispensable to me’ moment, but according to the latter the former Prime Minister did offer such sentiment in private. In an unguarded moment, Keating allegedly said that Watson would “be able to say that [he, Watson, was] the puppet master for the biggest puppet in the land” (Watson 290). If this comment was indeed offered, then Keating, much like Kennedy, (at least once) privately acknowledged the significant role that his speechwriter played in his administration. Watson, for his part, was less reticent. On the ABC’s Q&A of 29 August 2011 he assessed the relationship as being akin to a [then] “requited” love. Of course, above and beyond private or public acknowledgement of collaboration is tangible evidence of such: minuted meetings between speechwriter and speech-giver and instructions to the speechwriter that appear, for example, in a politician’s own hand. Perhaps more importantly, the stamp of ownership on a speech can be signalled by marginalia concerning delivery and in the context of the delivery itself: the engagement of emphases, pause, and the various paralinguistic phenomena that can add so much character to—and very much define—a written text. By way of example we reference again the unique and impassioned delivery of the Berlin speech, above. And beyond this again, as also suggested, are the non-written departures from a script that further put the stamp of ownership on an oration. In the case of Kennedy, it is easy to trace such marginalia and resultant departures from scripted material but there is little evidence that Keating either extensively annotated or extemporaneously departed from the script in question. However, as Tom Clark points out, while there are very few changes to Watson’s words there are fairly numerous “annotations that mark up timing, emphasis, and phrase coherence.” Clark points out that Keating had a relatively systematic notational schema “to guide him in the speech performance” (op. cit.). In engaging a musical analogy (an assemblage device that we ourselves employ), he opines that these scorings, “suggest a powerful sense of fidelity to the manuscript as authoritative composition” (op. cit.). While this is so, we argue—and one can easily conceive Keating arguing—that they are also marks of textual ownership; the former Prime Minister’s ‘signature’ on the piece. This is a point to which we return. For now, we note that matters of stress, rhythm, intonation, gesture, and body language are crucial to the delivery of a speech and reaffirm the point that it is in its delivery that an adroitly rendered text might come to life. As Sorensen (2008) reflects:I do not dismiss the potential of the right speech on the right topic delivered by the right speaker in the right way at the right moment. It can ignite a fire, change men’s minds, open their eyes, alter their votes, bring hope to their lives, and, in all these ways, change the world. I know. I saw it happen. (143)We argue that it is in its delivery to (and acceptance by) the patron and in its subsequent delivery by the patron to an audience that a previously written speech (co-authored, or not) may be ‘owned’. As we have seen, with respect to questions of authorship or craftsmanship, analogies (another device of method assemblage) with the visual and musical arts are not uncommon—and we here offer another: a reference to the architectural arts. When a client briefs an architect, the architect must interpret the client’s vision. Once the blueprints are passed to the client and are approved, the client takes ownership of work that has been, in a sense, co-authored. Ownership and authorship are not the same, then, and we suggest that it is the interstices that the tensions between Keating and Watson truly lie.In crafting the Redfern address, there is little doubt that Watson’s mind rolled in unison with the Prime Minister’s: invisible, intuited ‘evidence’ of a fruitful collaboration. As the former Prime Minister puts it: “Watson and I actually write in very similar ways. He is a prettier writer than I am, but not a more pungent one. So, after a pre-draft conference on a speech—canvassing the kind of things I thought we should say and include—unless the actual writing was off the beam, I would give the speech more or less off the printer” (Keating). As one of the present authors has elsewhere observed, “Watson sensed the Prime Minister’s mood and anticipated his language and even the pattern of his voice” (Foye 19). Here, there are shades of the Kennedy/Sorensen partnership. As Schlesinger Jr. observes, Kennedy and Sorensen worked so closely together that it became impossible to know which of them “originated the device of staccato phrases … or the use of balanced sentences … their styles had fused into one” (598). Moreover, in responding to a Sunday Herald poll asking readers to name Australia’s great orators, Denise Davies remarked, “Watson wrote the way Keating thought and spoke” (qtd. in Dale 46). Despite an uncompromising, pungent, title—‘On that historic day in Redfern, the words I spoke were mine’—Keating’s SMH op-ed of 26 August 2010 nonetheless offers a number of insights vis-a-vis the collaboration between speechwriter and speech-giver. To Keating’s mind (and here we might reflect on Sorensen’s observation about knowing the beliefs of the patron), the inspiration for the Prime Minister’s Redfern Address came from conversations between he and Watson.Keating relates an instance when, on a flight crossing outback Western Australia, he told Watson that “we will never really get Australia right until we come to terms with them (Keating).” “Them”, Keating explains, refers to Aborigines. Keating goes on to suggest that by “come to terms”, he meant “owning up to dispossession” (op. cit.)—which is precisely what he did, to everyone’s great surprise, in the speech itself. Keating observes: I remember well talking to Watson a number of times about stories told to me through families [he] knew, of putting “dampers” out for Aborigines. The dampers were hampers of poisoned food provided only to murder them. I used to say to Watson that this stuff had to be owned up to. And it was me who established the inquiry into the Stolen Generation that Kevin Rudd apologised to. The generation who were taken from their mothers.So, the sentiments that “we did the dispossessing … we brought the diseases, the alcohol, that we committed the murders and took the children from their mothers” were my sentiments. P.J. Keating’s sentiments. They may have been Watson’s sentiments also. But they were sentiments provided to a speechwriter as a remit, as an instruction, as guidance as to how this subject should be dealt with in a literary way. (op. cit.)While such conversations might not accurately be called “guidance” (something more consciously offered as such) or “instruction” (as Keating declares), they nonetheless offer to the speechwriter a sense of the trajectory of a leader’s thoughts and sentiments. As Keating puts it, “the sentiments of the speech, that is, the core of its authority and authorship, were mine” (op. cit.). As does Sorensen, Keating argues that that such revelation is a source of “power to the speechwriter” (op. cit.). This he buttresses with more down to earth language: conversations of this nature are “meat and drink”, “the guidance from which the authority and authorship of the speech ultimately derives” (op. cit.). Here, Keating gets close to what may be concluded: while authorship might, to a significant extent, be contingent on the kind of interaction described, ownership is absolutely contingent on authority. As Keating asserts, “in the end, the vector force of the power and what to do with it could only come from me” (op. cit.). In other words, no Prime Minister with the right sentiments and the courage to deliver them publicly (i.e. Keating), no speech.On the other hand, we also argue that Watson’s part in crafting the Redfern Address should not be downplayed, requiring (as the speech did) his unique writing style—called “prettier” by the former Prime Minister. More importantly, we argue that the speech contains a point of view that may be attributed to Watson more than Keating’s description of the speechwriting process might suggest. In particular, the Redfern Address invoked a particular interpretation of Australian history that can be attributed to Watson, whose manuscript Keating accepted. Historian Manning Clark had an undeniable impact on Watson’s thinking and thus the development of the Redfern address. Per Keating’s claim that he himself had “only read bits and pieces of Manning’s histories” (Curran 285), the basis for this link is actual and direct: Keating hired Clark devotee Watson as a major speech writer on the same day that Clark died in 1991 (McKenna 71). McKenna’s examination of Clark’s history reveals striking similarities with the rhetoric at the heart of the Redfern address. For example, in his 1988 essay The Beginning of Wisdom, Clark (in McKenna) announces:Now we are beginning to take the blinkers off our eyes. Now we are ready to face the truth about our past, to acknowledge that the coming of the British was the occasion of three great evils: the violence against the original inhabitants of the of the country, the Aborigines, the violence against the first European labour force in Australia, the convicts and the violence done to the land itself. (71)As the above quote demonstrates, echoes of Clark’s denouncement of Australia’s past are evident in the Redfern Address’ rhetoric. While Keating is correct to suggest that Watson and he shared the sentiments behind the Address, it may be said that it took Watson—steeped as he was in Clark’s understanding of history and operating closely as he did with the Prime Minister—to craft the Redfern Address. Notwithstanding the concept of ownership, Keating’s claim that the “vector force” for the speech could only come from him unreasonably diminishes Watson’s role.ConclusionThis article has considered the question of authorship surrounding the 1992 Redfern Address, particularly in view of the collaborative nature of speechwriting. The article has also drawn on the analogous relationship between President Kennedy and his Counsel, Ted Sorensen—an association that produced historic speeches. Here, the process of speechwriting has been demonstrated to be a synergistic collaboration between speechwriter and speech-giver; a working partnership in which the former translates the vision of the latter into words that, if delivered appropriately, capture audience attention and sympathy. At its best, this collaborative relationship sees the emergence of a synergy so complete that it is impossible to discern who wrote what (exactly). While the speech carries the imprimatur and original vision of the patron/public actor, this originator nonetheless requires the expertise of one (or more) who might give shape, clarity, and colour to what might amount to mere instructive gesture—informed, in the cases of Sorensen and Watson, by years of conversation. While ‘ownership’ of a speech then ultimately rests with the power-bearer (Keating requested, received, lightly edited, ‘scored’, and delivered—with some minor ad libbing, toward the end—the Redfern text), the authors of this article consider neither Keating nor Watson to be the major scribe of the Redfern Address. Indeed, it was a distinguished collaboration between these figures that produced the speech: a cooperative undertaking similar to the process of writing this article itself. Moreover, because an Australian Prime Minister brought the plight of Indigenous Australians to the attention of their non-Indigenous counterparts, the address is seminal in Australian history. It is, furthermore, an exquisitely crafted document. And it was also delivered with style. As such, the Redfern Address is memorable in ways similar to Kennedy’s inaugural, Berlin, and Peace speeches: all products of exquisite collaboration and, with respect to ownership, emblems of rare leadership.ReferencesAdams, Phillip. Backstage Politics: Fifty Years of Political Memories. London: Viking, 2010.Beale, Jennifer. Personal interview. 15 Dec. 2016.Clark, Tom. “Paul Keating’s Redfern Park Speech and Its Rhetorical Legacy.” Overland 213 (Summer 2013). <https://overland.org.au/previous-issues/issue-213/feature-tom-clarke/ Accessed 16 January 2017>.Curran, James. The Power of Speech: Australian Prime Ministers Defining the National Image. Melbourne: Melbourne UP, 2004.Dale, Denise. “Speech Therapy – How Do You Rate the Orators.” Sun Herald, 9 Mar.2008: 48.Dallek, Robert. An Unfinished Life: John F. Kennedy 1917-1963. New York: Little Brown, 2003.Foye, Jonathan. Visions and Revisions: A Media Analysis of Reconciliation Discourse, 1992-2008. Honours Thesis. Sydney: Western Sydney University, 2009.Glover, Denis. “Redfern Speech Flatters Writer as Well as Orator.” The Australian 27 Aug. 2010. 15 Jan. 2017 <http://www.theaustralian.com.au/national-affairs/opinion/redfern-speech-flatters-writer-as-well-as-orator/news-story/b1f22d73f67c29f33231ac9c8c21439b?nk=33a002f4d3de55f3508954382de2c923-1489964982>.Goldhamer, Herbert. The Adviser. Amsterdam: Elsevier, 1978.Keating, Paul. “On That Historic Day in Redfern the Words I Spoke Were Mine.” Sydney Morning Herald 26 Aug. 2010. 15 Jan. 2017 <http://www.smh.com.au/federal-politics/political-opinion/on-that-historic-day-in-redfern-the-words-i-spoke-were-mine-20100825-13s5w.html>.———. “Redfern Address.” Address to mark the International Year of the World's Indigenous People. Sydney: Redfern Park, 10 Dec. 1992. Law, John. After Method: Mess in Social Science Research. New York: Routledge, 2004. McKenna, Mark. “Metaphors of Light and Darkness: The Politics of ‘Black Armband’ History.” Melbourne Journal of Politics 25.1 (1998): 67-84.Megalogenis, George. “The Book of Paul: Lessons in Leadership.” The Monthly, Nov. 2011: 28-34.Schlesinger Jr., Arthur M. A Thousand Days: John F. Kennedy in the White House. Andre Deutsch, 1967.Sorensen, Ted. Counselor: A Life at the Edge of History. New York: Harper Collins, 2008.Tubridy, Ryan. JFK in Ireland. New York: Harper Collins, 2010.Watson, Don. Recollections of a Bleeding Heart: A Portrait of Paul Keating PM. Milsons Point: Knopf, 2002.———. Q&A. ABC TV, 29 Aug. 2011.Whiticker, Alan. J. Speeches That Shaped the Modern World. New York: New Holland, 2005.Von Drehle, David. JFK: His Enduring Legacy. Time Inc Specials, 2013.

Introduction: One in three adults in the United States has hypertension, and no significant changes in the prevalence of hypertension have been noted in the past decade. Participation in physical activity can aid in the prevention and control of hypertension, yet prevalence of physical activity participation remains low. The purpose of this study was to assess the prevalence of meeting aerobic guidelines for physical activity by hypertensive status, and to examine the associations between physical activity and hypertension treatment and control. Methods: Data from the National Health and Nutrition Examination Survey 1999-2006 were used to allow for more detailed analyses and due to consistency of physical activity measures. Hypertension was defined by blood pressure (BP) ≥140/90mmHg or taking BP medications; treated (i.e., BP medications) and controlled (<140/90mmHg) hypertension was defined among those with hypertension. Physical activity was categorized by minutes per week of aerobic physical activity based on 2008 Physical Activity Guidelines for Americans (2008 Guidelines) (inactive, <10; insufficiently active, 10-149; active, ≥150-300; highly active, >300). Additional variables included sociodemographic and lifestyle characteristics (i.e., smoking, alcohol, sodium intake, fruit and vegetable intake). Participants <18 years of age, pregnant, or missing data for study variables were excluded, resulting in an analytic sample of 12,040. Univariate analysis was used to calculate prevalence estimates and 95% confidence intervals (95%CI). Multivariable logistic regression analysis was used for calculating odds ratios (OR). Results: Significantly fewer adults with hypertension were active or highly active (31.9%, 95%CI: 29.4, 34.0) compared to those without hypertension (45.3%, 95%CI: 43.3, 47.4) (p<0.01). Among those with treated hypertension, 30.1% (95%CI: 27.7, 32.6) were active or highly active, compared to 34.5% (95%CI: 30.8, 38.3) who were not treated (p<0.05). Following adjustments for sociodemographic and lifestyle characteristics, adults meeting 2008 Guidelines (i.e., active or highly active) were less likely to be hypertensive compared to adults who did not meet 2008 Guidelines (OR: 0.77, 95%CI: 0.67, 0.87). Meeting 2008 Guidelines was not significantly associated with either treatment or control of hypertension. Discussion: Adults with hypertension are less likely to meet the 2008 Guidelines , compared to those without hypertension. Those with treated hypertension were less likely to meet 2008 Guidelines than those not treated. Clinicians should counsel all of their patients about physical activity as recommended in clinical guidelines, and evidence-based community-wide efforts and policies that support opportunities to participate in physical activity should be encouraged.

The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires. — William Arthur WardIntroductionThe first documented use of the term Mentor can be traced back to the 8th century BC poem by Homer entitled Odyssey (Hay, Gerber and Minichiello). Although this original representation of Mentor is contested in the literature (Colley), historically the term mentor has evolved to imply a wise and trusted other who advises, teaches, protects and supports someone younger who is inexperienced and not so knowledgeable with the ways of the world. The mentor within a 21st century construct still aligns to this historical portrayal, however the evolution of society, the influence of technology, the growth of entrepreneurship, and a greater understanding of the impact of our interactions with others has forced us to consider mentoring in contemporary ways. As such, popular culture, through books, film and images, provide many impressions of the mentor and what it means to mentor in both historical and contemporary circumstances. Similarly, popular culture provides us with a variety of impressions of the teacher. Throughout old and new history, teaching is considered to be a honourable profession, one that is complex and involves specific skills and knowledge to be effective (Marsh). Society has high expectations of teachers as they are entrusted with shaping the future generation (Parkay). Although the levels of respect and trust of teachers changes within different cultural circumstances, society allows teachers to be one of the most influential figures in a child’s life. Popular film often picks up on this theme and portrays teachers as inspirational figures, pillars of society and those that can have a major influence over the development of the student’s in their care. Within the brief story that a film provides, teachers are more often than not, positioned as a ‘mentor type’ figure to the students entrusted in their care, who guides and supports them to become who they want to be. This paper explores the constructs of the mentor and mentorship through a popular culture lens. Culture is broadly described as the “bricks and mortar of our most commonplace understandings” (Willis 185) and our understandings are shaped by what we see, hear and do. The paper is framed by and seeks to answer the following question: To what extent is the teacher as mentor portrayed in popular film a realistic image? Accordingly this paper will examine the rise of the teacher as mentor and determine what images are portrayed through the medium of film. In order to answer the question, the paper will briefly examine current literature for the characteristics and roles of mentors and teachers. The paper will then delve into the way that teachers are portrayed in film and will be followed by an examination of a selection of films that portray teachers as mentors. A comparison will be made between the characteristics of mentors and the characteristics that the movie teachers display. Analysis through the use of reader-response theory will provide insight into the extent of the reality of the teacher as mentor that are portrayed. Mentors and Teachers: A Review of Selected Literature Mentoring consists of a series of interactions that can be of a social, intellectual or emotional nature (Lentz and Allen). Mentoring can be described as a helping relationship whereby two or more people work together in order to achieve personal and professional goals (Johnson and Ridley). Effective mentoring is also known to be mutually beneficial to all participants (Ambrosetti, Knight and Dekkers). When scanning the literature there are a number of common descriptors that are used consistently to situate the interactions a mentor undertakes: supporter, guide, advisor, teacher, protector and counselor (Sundli; Hall et al.). Such descriptors indicate that a mentor performs a series of roles that change according to the needs of those being mentored (Ambrosetti and Dekkers). If the mentor has a series of roles to perform, then it is logical that the mentee also will also have a number of roles to play, however these are lnot well documented in the literature. The roles that both mentors and mentees play during a relationship can be identified and underpinned through the three dimensions of mentoring: the relationship itself, the developmental needs of the participants and the integration of the context in which the mentoring is situated (Ambrosetti, Knight and Dekkers). The interactions that a mentor engages in with a mentee span over a number of dimensions and are often reactive in nature. The three dimensions of mentoring can assist in describing a mentor and the roles they play. The relational dimension includes such roles as supporter, protector, friend and counselor. The roles of guide, teacher/trainer, collaborator, facilitator and reflector can be classified as developmental whereas being a role model can be both a developmental role and contextual role (230). There are a number of characteristics that are common to a mentor. Johnson and Ridley summarize them to include the following traits: exuding warmth, listening actively, showing unconditional regard, tolerating idealization, embracing humor, not expecting perfection, being trustworthy, having interpersonal competence, respecting another’s values and not being jealous of the mentee (43-62). The above list of traits are personal and often linked to personality, thus can be connected explicitly to the relational dimension of mentoring. The possession (or non-possession) of such traits can impact on the interactions that occur within mentorship. Accordingly it can be assumed that the characteristics, in conjunction with the roles that mentors play, that not everyone is suited to the role of mentor. Most people have experienced schooling at some stage in their life and is therefore familiar with the role of a teacher. Teaching is one most well known professions and can be described as a “creative act in which teachers continually shape and reshape lessons, events and the experiences of their students”(Parkay 45). The role of a teacher is to teach both knowledge and skills to their learners in order to prepare them as citizens for the future. More specifically, the role of the teacher is to design and deliver learning experiences that cater for and challenge the learners, that develop skills and knowledge both inside and outside of the classroom, and help them become confident, creative and responsible citizens. Despite this important role, the image of teachers is split between two types: one that is bitter, spiteful and egocentric, and the other being caring, accepting and reflective (Connell). We remember teachers according to such categories. The types of characteristics that teachers hold are extensive, however the following encompasses those that are key within the literature. Teachers generally have compassion, empathy and a caring nature. They can be flexible, creative, personable, humorous, positive, knowledgeable, motivational and dependable. Teachers are often well organised people, fair minded and resourceful (Howell). When examining the characteristics of teachers and the traits of mentors, similarities can be seen indicating that a particular type of person may be more suited to being a teacher and/or mentor. Teachers as Mentors in Film Teachers seem to be a popular subject of feature films. Films such as Goodbye Mr Chips (1939), Blackboard Jungle (1955) and To Sir with Love (1967) provide us with insight into the way teachers are portrayed in society and the role they play. Film however, has the specific ability to shape the cultural understanding we develop and allows us to make comparisons to our own experiences and those that are played out in fictional circumstances (Delamarter). While there are some films that provide a negative portrayal of teachers, generally they provide a view that teachers are positive influences on the students in their care.A search of the World Wide Web about the teacher as mentor brings up a treasure trove of film titles that span from the 1930s to the present day. Despite such a choice of titles, the following films have been selected to examine in this paper: Dead Poets Society (1989), Dangerous Minds (1995), Freedom Writers (2007) and the Harry Potter series of films (2001-2011). Selection of these films was based on the following two criteria: 1) they occurred within in a school setting and 2) are embedded within a contemporary theme of struggle where rebellion and/or other teenage angst are highlighted. Reader-response theory will underpin the analysis of the teachers in each of the films selected, so that an answer to the earlier posed question can be illuminated. Broadly speaking, reader-response theory is concerned with how readers, or in this case viewers, “make meaning from their experience with the text” (Beach 1). There are many perspectives on reader-response theory and how one might focus upon when responding to a text. In this instance the author will highlight the transaction that occurs between the reader, the text and the context. The transactions will include the social, cultural, experiential, psychological and textual viewpoints (Beach 8). Firstly, each film will be briefly described. This will be followed by an analysis of the teachers portrayed in the films. Dead Poets Society (1989) is set at a conservative secondary boys academy in the late 1950s and focuses on a group of students completing their senior year. Mr Keating is a new English teacher who uses unconventional teaching methods in the classroom. He inspires his students to ‘seize the day’ and ‘make your lives extraordinary’ and does this through the teaching of poetry. He encourages them to stand on desks during his lessons and to throw out tradition. It is Keating’s messages to his students to question what they believe that permeates the film and inspires his students to pursue what they want to do and become. The film Dangerous Minds (1995) is set in a low socio-economic area, where un-privilege and protecting yourself is a way of life. The teacher in this film is new and young, but is an ex US Marine. The class the film centres on is a difficult one to teach. This teacher uses unorthodox methods to gain the attention and trust of her students. The film makes a point to show us that she makes particular effort to relate the curriculum to the students’ interests in order to engage them in learning. Emphasis is also on the fact that she takes an interest in the students and many become her ‘personal projects’ and helping them to realize who they can become. Freedom Writers (2007) is set in the years directly following the Los Angeles riots of 1992 whereby issues of racism, segregation and inequality along with the changing view of the world is the focus. The students in the classrooms of this film are from diverse backgrounds and un-trusting of the education system. Their teacher is new and young and her first attempts to earn their trust fail until she begins to get to know the students and make links between what is being taught to their own lives. She inspires her class to learn tolerance, apply themselves and pursue further education. In the Harry Potter (2001-2011) series of films, there are several teachers who make an impact upon the young wizards. Although set in a fantasy world, the audience is treated to both inspirational teachers looking to nurture, protect and develop their charges, and teachers who are painted as egocentric and suspicious. Inspirational teachers include Dumbledore and McGonagall who offer subtle life lessons, specific skills and knowledge and protect the young wizards from danger. Egocentric and somewhat suspicious teachers include Snape and Quirrell who look to thwart the wizard’s time at school, however they too offer subtle life lessons to their students. The theme of good versus evil is paramount throughout the film series and the teachers are aligned with this theme.Teachers as Mentors – An AnalysisAlthough only a brief description of each film has been offered, the teachers as mentors to their students is the focus. Mr Keating (Dead Poets Society) and LouAnne Johnson (Dangerous Minds) are both described as unorthodox as they each use teaching methods that are frowned upon by others. However their purposeful and different teaching methods draw their students into their lessons so that life learning can occur. In each film, the unorthodox teaching touches the students in ways unknown to them before and in both cases the students demonstrate intellectual and personal growth. The unorthodox methods provide an avenue for a different relationship that is far from the traditional. In some scenes friendship is hinted at where guiding and supporting the students towards their hopes and dreams is highlighted. Aspects of mentoring can be seen through relational, developmental and contextual domains as the students are supported, guided and provided explicit role modeling. The young teacher in Freedom Writers, Erin Gruwell, uses a teaching approach that includes taking time to get to know her students. This approach, like Keating and Johnson, provides the opportunity to tweak the curriculum to the interests of the students and thus engage them in academic learning. They teach skills and knowledge in ways which relate to the students’ lives and interests. They guide, support the students towards the unfamiliar and facilitate opportunities for success. They help them to set goals and make them realise that they have a future and can be successful in their lives. The transformations that occur due to the teaching approaches used by the teachers cause their students admire and want to be like them. In Harry Potter, teachers Dumbledore and McGonagall are wise in years and life experience. They offer wisdom, protection and guidance to the young wizards throughout the series. These teachers, like Keating, Johnson and Gruwell, are role models in that they represent what life can be like and how best to achieve that life. Snape and Quirell also take an interest in their students, but represent an alternative view of life and learning. The difference between the four Harry Potter teachers can be drilled down to the traits of effective teachers. Two of which emulate the traits and two whom do not readily display any of the traits. Dumbledore and McGonagall can be considered as teacher mentors whereas Snape and Quirell cannot. In each film the student can be seen as central to the teacher as mentor and this in turn influences the way in which they behave. The teachers in these films pass on life lessons through their teaching. Throughout the films the teachers are guiding, supporting, befriending, protecting and training their charges. Interactions that occur between the teachers and the students are followed by a reflective phase by the teachers, whereby solutions to problems are sought or self-realisation occurs. In many instances the films show the teacher learning from the student and thus learning their own life lessons through reflection. From a social and cultural perspective, what is portrayed within the storylines are often close to the reality of what is expected from teachers. In many instances these lead towards a stereotyping of who teachers are and how they behave. However, from an experiential point of view, our expectations of the actions that teachers undertake do not usually take such form. In reality, teachers are busy people with a complex job to do (Connell) and often do not have time to take personal interest in all of their students individually. The teachers within the films chosen seem to have one class to prepare for, whereas in reality, a school teacher will have many classes to consider. Psychologically, some teachers and the style they embrace appeal to a particular a type of student or group of students. In the case of Dead Poets Society, Dangerous Minds and Freedom Writers, the storyline painted the students as those needing a particular type of teacher, someone who would save them from their circumstance and visa versa. The textual perspective was well highlighted by the teachers in the Harry Potter films as the viewer expects to see teachers with rather unusual but interesting teaching styles. However the text (within all films) included insight into mentor characteristics such as warmth, humour, tolerance, respect and unconditional regards. Generally, the films examined highlight two different types of teachers, challenging the categories written about by Connell. The first type of teacher highlighted was one who was seen as being more contemporary. One who is individual, unorthodox, and maybe a little rebellious; this teacher highlights that you need to be ‘different’ to make a difference. The second type was one who aligns to the traditional form of teacher; one who uses their knowledge, wisdom and life experience to break through to their student. Each of the films were underpinned by the relationship, the developmental needs and the context in which the narrative was played out, however the relationship between the students and the teacher was highlighted as being central to the storyline. Thus films of this nature often portray teachers as those who help their students in the emotional sense rather than the intellectual sense (Delamarter). Conclusion Several understandings about the teacher as mentor have been brought to light through the examination of the teacher as mentor in film. Firstly, in revisiting the mentoring definitions offered within this paper, it can be said that the teachers highlighted in the discussed films were mentoring their students in a way unique to the relationship developed between teacher and student. In each instance the teacher worked with their students to identify teaching approaches that would be successful in the context in which they were situated. Each film demonstrated that the teachers were committed to creating a relationship that met the developmental needs of their students. Interestingly, it was observed that the relationships were mutually beneficial in that the teachers grew along with the students with many coming to realisations about themselves through reflection and self thought. Secondly, the teachers within the films were portrayed as playing several important roles within their students’ lives. The teachers were role models inside and outside of the classroom. Each film’s storyline positioned the teacher as an influential other, whether they be portrayed as rebellious and unorthodox, evil and suspicious or inspirational and wise. The teachers in these films can be considered as mentors as they were supporting, guiding, protecting and nurturing the students to become better versions of themselves. However, the question that this article sought to answer was: to what extent is the teacher as mentor portrayed in popular film a realistic image? In looking back at the image the teacher in society and the role that they play in developing citizens of the future, it can be said the image presented has slivers of realism. In the real world, teachers must conform to society’s expectations, educational policies and codes of professionalism. Professional relationships with students do not encompass them in behave a student as a ‘personal project’, although catering to their needs is encouraged within the curriculum. It would be thought that if teachers did not encourage their students to be the best they can be, then they would not be doing their job. Many figures throughout our cultural history have been viewed as a mentor due to the role they play and how these roles align to societal beliefs and values. Thus, the portrayal of mentors and mentorship through a popular culture lens provides insight into our understanding about what mentorship is and how this may develop in the future. Both in the past and present, teachers are seen as inspirational figures and pillars of society, and are often considered a mentor by default. Films portray teachers in a variety of fashions, however there are many films that subtly position the teacher as a mentor to their students and it is this that this article has focused on. ReferencesAmbrosetti, Angelina, and John Dekkers. “The Interconnectedness of the Roles of Mentors and Mentees in Pre-Service Teacher Education Mentoring Relationships.” Australian Journal of Teacher Education 35.6 (2010): 42-55.Ambrosetti, Angelina, Bruce Allen Knight, and John Dekkers. “Maximizing the Potential of Mentoring: A Framework for Pre-Service Teacher Education.” Mentoring and Tutoring: Partnership in Learning 22.3 (2014): 224-39.Beach, Richard. A Teacher’s Response to Reader-Response Theories. Illinois: National Council Teachers of English, 1993.Blackboard Jungle. Directed by Richard Brooks. Metro-Goldwyn-Mayer, 1955.Colley, Helen. “Righting Rewritings of the Myth of Mentor: A Critical Perspective on Career Guidance Mentoring.” British Journal of Guidance & Counselling 29.2 (2001): 177-197.Connell, Raewyn. “Teachers.” Education, Change and Society. Eds. Raewyn Connell, Anthony Welch, Margaret Vickers, Dennis Foley, Nigel Bagnall, Debra Hayes, Helen Proctor, Arathi Sriprakash, and Craig Campbell. South Melbourne: Oxford, 2013. 261-275.Dangerous Minds. Directed by John N. Smith. Hollywood Pictures/Don Simpson/Jerry Bruckheimer Films/Via Rosa Productions, 1995.Dead Poets Society. Directed by Peter Weir. Touchstone Pictures/Silver Screen Partners IV, 1989.Delamater, Jeremy. “Avoiding Practice Shock: Using Teacher Movies to Realign Pre-Service Teachers’ Expectations of Teaching.” Australian Journal of Teacher Education 40.2 (2015): 1-14.Freedom Writers. Directed by Richard LaGravenese. Paramount Pictures, 2007.Goodbye Mr Chips. Directed by Sam Wood. Metro-Goldwyn-Mayer Denham Studios, 1939.Hall, Kendra M., Rani Jo Draper, Leigh K. Smith, and Robert V. Bullough. “More than a Place to Teach: Exploring the Perceptions of the Roles and Responsibilities of Mentor Teachers.” Mentoring and Tutoring: Partnership in Learning 16.3 (2008): 328-45.Harry Potter and the Philosopher’s Stone. Directed by Chris Columbus. Heyday Films/1492 Pictures, 2001.Hay, Terence, Rod Gerber, and Victor Minichiello. “Mentorship: A Review of the Concept.” Unicorn 25.2 (1999): 84-95.Howell, Jennifer. Teaching and Learning: Building Effective Pedagogies. South Melbourne, Vic.: Oxford University Press, 2014.Lentz, Elizabeth, and Tammy D. Allen. “Reflections on Naturally Occurring Mentoring Relationships.” The Blackwell Handbook of Mentoring: A Multiple Perspectives Approach. Eds. Tammy D. Allen and Lillian T. Eby. Malden, MA: Blackwell, 2007. 159-162.Johnson, W. Brad, and Charles R. Ridley. The Elements of Mentoring. New York, NY: Palgrave Macmillan, 2004. Marsh, Colin. Becoming a Teacher: Knowledge Skills and Issues. 5th ed. Frenchs Forest Pearson, 2010.Parkay, Forrest W. Becoming a Teacher. 9th ed. Upper Saddle River, NJ: Pearson.Sundli, Liv. “Mentoring: A New Mantra for Education?” Teaching and Teacher Education 23 (2007): 201-14.To Sir with Love. Directed by James Clavell. Columbia British Productions, 1967.Willis, Paul. “Shop-Floor Culture, Masculinity and the Wage Form.” Working Class Culture: Studies in History and Theory. Eds. John Clarke, Chas Critcher, and Richard Johnson. Abingdon, Oxon: Routledge, 2007. 185-200.

In this paper we explore the rise of anti-gambling apps in the context of the massive expansion of gambling in new spheres of life (online and offline) and an acceleration in strategies of anticipatory and individualised management of harm caused by gambling. These apps, and the techniques and forms of labour they demand, are examples of and a mechanism through which a mode of governance premised on ‘self-care’ and ‘self-control’ is articulated and put into practice. To support this argument, we explore two government initiatives in the Australian context. Quit Pokies, a mobile app project between the Moreland City Council, North East Primary Care Partnership and the Victorian Local Governance Association, is an example of an emerging service paradigm of ‘self-care’ that uses online and mobile platforms with geo-location to deliver real time health and support interventions. A similar mobile app, Gambling Terminator, was launched by the NSW government in late 2012. Both apps work on the premise that interrupting a gaming session through a trigger, described by Quit Pokies’ creator as a “tap on the shoulder” provides gamblers the opportunity to take a reflexive stance and cut short their gambling practice in the course of play. We critically examine these apps as self-disciplining techniques of contemporary neo-liberalism directed towards anticipating and reducing the personal harm and social risk associated with gambling. We analyse the material and discursive elements, and new forms of user labour, through which this consumable media is framed and assembled. We argue that understanding the role of these apps, and mobile media more generally, in generating new techniques and technologies of the self, is important for identifying emerging modes of governance and their implications at a time when gambling is going through an immense period of cultural normalisation in online and offline environments. The Australian context is particularly germane for the way gambling permeates everyday spaces of sociality and leisure, and the potential of gambling interventions to interrupt and re-configure these spaces and institute a new kind of subject-state relation. Gambling in Australia Though a global phenomenon, the growth and expansion of gambling manifests distinctly in Australia because of its long cultural and historical attachment to games of chance. Australians are among the biggest betters and losers in the world (Ziolkowski), mainly on Electronic Gaming Machines (EGM) or pokies. As of 2013, according to The World Count of Gaming Machine (Ziolkowski), there were 198,150 EGMs in the country, of which 197,274 were slot machines, with the rest being electronic table games of roulette, blackjack and poker. There are 118 persons per machine in Australia. New South Wales is the jurisdiction with most EGMs (95,799), followed by Queensland (46,680) and Victoria (28,758) (Ziolkowski). Gambling is significant in Australian cultural history and average Australian households spend at least some money on different forms of gambling, from pokies to scratch cards, every year (Worthington et al.). In 1985, long-time gambling researcher Geoffrey Caldwell stated thatAustralians seem to take a pride in the belief that we are a nation of gamblers. Thus we do not appear to be ashamed of our gambling instincts, habits and practices. Gambling is regarded by most Australians as a normal, everyday practice in contrast to the view that gambling is a sinful activity which weakens the moral fibre of the individual and the community. (Caldwell 18) The omnipresence of gambling opportunities in most Australian states has been further facilitated by the availability of online and mobile gambling and gambling-like spaces. Social casino apps, for instance, are widely popular in Australia. The slots social casino app Slotomania was the most downloaded product in the iTunes store in 2012 (Metherell). In response to the high rate of different forms of gambling in Australia, a range of disparate interest groups have identified the expansion of gambling as a concerning trend. Health researchers have pointed out that online gamblers have a higher risk of experiencing problems with gambling (at 30%) compared to 15% in offline bettors (Hastings). The incidence of gambling problems is also disproportionately high in specific vulnerable demographics, including university students (Cervini), young adults prone to substance abuse problems (Hayatbakhsh et al.), migrants (Tanasornnarong et al.; Scull & Woolcock; Ohtsuka & Ohtsuka), pensioners (Hing & Breen), female players (Lee), Aboriginal communities (Young et al.; McMillen & Donnelly) and individuals experiencing homelessness (Holsworth et al.). While there is general recognition of the personal and public health impacts of gambling in Australia, there is a contradiction in the approach to gambling at a governance level. On one hand, its expansion is promoted and even encouraged by the federal and state governments, as gambling is an enormous source of revenue, as evidenced, for example, by the construction of the new Crown casino in Barangaroo in Sydney (Markham & Young). Campaigns trying to limit the use of poker machines, which are associated with concerns over problem gambling and addiction, are deemed by the gambling lobby as un-Australian. Paradoxically, efforts to restrict gambling or control gambling winnings have also been described as un-Australian, such as in the Australian Taxation Office’s campaign against MONA’s founder, David Walsh, whose immense art collection was acquired with the funds from a gambling scheme (Global Mail). On the other hand, people experiencing problems with gambling are often categorised as addicts and the ultimate blame (and responsibility) is attributed to the individual. In Australia, attitudes towards people who are arguably addicted to gambling are different than those towards individuals afflicted by alcohol or drug abuse (Jean). While “Australians tend to be sympathetic towards people with alcohol and other drug addictions who seek help,” unless it is seen as one of the more socially acceptable forms of occasional, controlled gambling (such as sports betting, gambling on the Melbourne Cup or celebrating ANZAC Day with Two-Up), gambling is framed as an individual “problem” and “moral failing” (Jean). The expansion of gambling is the backdrop to another development in health care and public health discourse, which have for some time now been devoted to the ideal of what Lupton has called the “digitally engaged patient” (Lupton). Technologies are central to the delivery of this model of health service provision that puts the patient at the centre of, and responsible for, their own health and medical care. Lupton has pointed out how this discourse, while appearing new, is in fact the latest version of the 1970s emphasis on the ‘patient as consumer’, an idea given an extra injection by the massive development and availability of digital and interactive web-based and mobile platforms, many of these directed towards the provision of health and health-related information and services. What this means for patients is that, rather than relying solely on professional medical expertise and care, the patient is encouraged to take on some of this medical/health work to conduct practices of ‘self-care’ (Lupton). The Discourse of ‘Self-Management’ and ‘Self-Care’ The model of ‘self-care’ and ‘self-management’ by ‘empowering’ digital technology has now become a dominant discourse within health and medicine, and is increasingly deployed across a range of related sectors such as welfare services. In recent research conducted on homelessness and mobile media, for example, government department staff involved in the reform of welfare services referred to ‘self-management’ as the new service paradigm that underpins their digital reform strategy. Echoing ideas and language similar to the “digitally engaged patient”, customers of Centrelink, Medicare and other ‘human services’ are being encouraged (through planned strategic initiatives aimed at shifting targeted customer groups online) to transact with government services digitally and manage their own personal profiles and health information. One departmental staff member described this in terms of an “opportunity cost”, the savings in time otherwise spent standing in long queues in service centres (Humphry). Rather than view these examples as isolated incidents taking place within or across sectors or disciplines, these are better understood as features of an emerging ‘discursive formation’ , a term Foucault used to describe the way in which particular institutions and/or the state establish a regime of truth, or an accepted social reality and which gives definition to a new historical episteme and subject: in this case that of the self-disciplined and “digitally engaged medical/health patient”. As Foucault explained, once this subject has become fully integrated into and across the social field, it is no longer easy to excavate, since it lies below the surface of articulation and is held together through everyday actions, habits and institutional routines and techniques that appear to be universal, necessary and/normal. The way in which this citizen subject becomes a universal model and norm, however, is not a straightforward or linear story and since we are in the midst of its rise, is not a story with a foretold conclusion. Nevertheless, across a range of different fields of governance: medicine; health and welfare, we can see signs of this emerging figure of the self-caring “digitally engaged patient” constituted from a range of different techniques and practices of self-governance. In Australia, this figure is at the centre of a concerted strategy of service digitisation involving a number of cross sector initiatives such as Australia’s National EHealth Strategy (2008), the National Digital Economy Strategy (2011) and the Australian Public Service Mobile Roadmap (2013). This figure of the self-caring “digitally engaged” patient, aligns well and is entirely compatible with neo-liberal formulations of the individual and the reduced role of the state as a provider of welfare and care. Berry refers to Foucault’s definition of neoliberalism as outlined in his lectures to the College de France as a “particular form of post-welfare state politics in which the state essentially outsources the responsibility of the ‘well-being' of the population” (65). In the case of gambling, the neoliberal defined state enables the wedding of two seemingly contradictory stances: promoting gambling as a major source of revenue and capitalisation on the one hand, and identifying and treating gambling addiction as an individual pursuit and potential risk on the other. Risk avoidance strategies are focused on particular groups of people who are targeted for self-treatment to avoid the harm of gambling addiction, which is similarly framed as individual rather than socially and systematically produced. What unites and makes possible this alignment of neoliberalism and the new “digitally engaged subject/patient” is first and foremost, the construction of a subject in a chronic state of ill health. This figure is positioned as terminal from the start. They are ‘sick’, a ‘patient’, an ‘addict’: in need of immediate and continuous treatment. Secondly, this neoliberal patient/addict is enabled (we could even go so far as to say ‘empowered’) by digital technology, especially smartphones and the apps available through these devices in the form of a myriad of applications for intervening and treating ones afflictions. These apps range fromself-tracking programs such as mood regulators through to social media interventions. Anti-Pokie Apps and the Neoliberal Gambler We now turn to two examples which illustrate this alignment between neoliberalism and the new “digitally engaged subject/patient” in relation to gambling. Anti-gambling apps function to both replace or ‘take the place’ of institutions and individuals actively involved in the treatment of problem gambling and re-engineer this service through the logics of ‘self-care’ and ‘self-management’. Here, we depart somewhat from Foucault’s model of disciplinary power summed up in the institution (with the prison exemplifying this disciplinary logic) and move towards Deleuze’s understanding of power as exerted by the State not through enclosures but through diffuse and rhizomatic information flows and technologies (Deleuze). At the same time, we retain Foucault’s attention to the role and agency of the user in this power-dynamic, identifiable in the technics of self-regulation and in his ideas on governmentality. We now turn to analyse these apps more closely, and explore the way in which these articulate and perform these disciplinary logics. The app Quit Pokies was a joint venture of the North East Primary Care Partnership, the Victorian Local Governance Association and the Moreland City Council, launched in early 2014. The idea of the rational, self-reflexive and agentic user is evident in the description of the app by app developer Susan Rennie who described it this way: What they need is for someone to tap them on the shoulder and tell them to get out of there… I thought the phone could be that tap on the shoulder. The “tap on the shoulder” feature uses geolocation and works by emitting a sound alert when the user enters a gaming venue. It also provides information about each user’s losses at that venue. This “tap on the shoulder” is both an alert and a reprimand from past gambling sessions. Through the Responsible Gambling Fund, the NSW government also launched an anti-pokie app in 2013, Gambling Terminator, including a similar feature. The app runs on Apple and Android smartphone platforms, and when a person is inside a gambling venue in New South Wales it: sends reminder messages that interrupt gaming-machine play and gives you a chance to re-think your choices. It also provides instant access to live phone and online counselling services which operate 24 hours a day, seven days a week. (Google Play Store) Yet an approach that tries to prevent harm by anticipating the harm that will come from gambling at the point of entering a venue, also eliminates the chance of potential negotiations and encounters a user might have during a visit to the pub and how this experience will unfold. It reduces the “tap on the shoulder”, which may involve a far wider set of interactions and affects, to a software operation and it frames the pub or the club (which under some conditions functions as hubs for socialization and community building) as dangerous places that should be avoided. This has the potential to lead to further stigmatisation of gamblers, their isolation and their exclusion from everyday spaces. Moreland Mayor, Councillor Tapinos captures the implicit framing of self-care as a private act in his explanation of the app as a method for problem gamblers to avoid being stigmatised by, for example, publicly attending group meetings. Yet, curiously, the app has the potential to create a new kind of public stigmatisation through potentially drawing other peoples’ attention to users’ gambling play (as the alarm is triggered) generating embarrassment and humiliation at being “caught out” in an act framed as aberrant and literally, “alarming”. Both Quit Pokies and Gambling Terminator require their users to perform ‘acts’ of physical and affective labour aimed at behaviour change and developing the skills of self-control. After downloading Quit Pokies on the iPhone and launching the app, the user is presented an initial request: “Before you set up this app. please write a list of the pokies venues that you regularly use because the app will ask you to identify these venues so it can send you alerts if you spend time in these locations. It will also use your set up location to identify other venues you might use so we recommend that you set up the App in the location where you spend most time. Congratulation on choosing Quit Pokies.”Self-performed processes include installation, setting up, updating the app software, programming in gambling venues to be detected by the smartphone’s inbuilt GPS, monitoring and responding to the program’s alerts and engaging in alternate “legitimate” forms of leisure such as going to the movies or the library, having coffee with a friend or browsing Facebook. These self-performed labours can be understood as ‘technologies of the self’, a term used by Foucault to describe the way in which social members are obliged to regulate and police their ‘selves’ through a range of different techniques. While Foucault traces the origins of ‘technologies of the self’ to the Greco-Roman texts with their emphasis on “care of oneself” as one of the duties of citizenry, he notes the shift to “self-knowledge” under Christianity around the 8th century, where it became bound up in ideals of self-renunciation and truth. Quit Pokies and Gambling Terminator may signal a recuperation of the ideal of self-care, over confession and disclosure. These apps institute a set of bodily activities and obligations directed to the user’s health and wellbeing, aided through activities of self-examination such as charting your recovery through a Recovery Diary and implementing a number of suggested “Strategies for Change” such as “writing a list” and “learning about ways to manage your money better”. Writing is central to the acts of self-examination. As Jeremy Prangnell, gambling counsellor from Mission Australia for Wollongong and Shellharbour regions explained the app is “like an electronic diary, which is a really common tool for people who are trying to change their behaviour” (Thompson). The labours required by users are also implicated in the functionality and performance of the platform itself suggesting the way in which ‘technologies of the self’ simultaneously function as a form of platform work: user labour that supports and sustains the operation of digital systems and is central to the performance and continuation of digital capitalism in general (Humphry, Demanding Media). In addition to the acts of labour performed on the self and platform, bodies are themselves potentially mobilised (and put into new circuits of consumption and production), as a result of triggers to nudge users away from gambling venues, towards a range of other cultural practices in alternative social spaces considered to be more legitimate.Conclusion Whether or not these technological interventions are effective or successful is yet to be tested. Indeed, the lack of recent activity in the community forums and preponderance of issues reported on installation and use suggests otherwise, pointing to a need for more empirical research into these developments. Regardless, what we’ve tried to identify is the way in which apps such as these embody a new kind of subject-state relation that emphasises self-control of gambling harm and hastens the divestment of institutional and social responsibility at a time when gambling is going through an immense period of expansion in many respects backed by and sanctioned by the state. Patterns of smartphone take up in the mainstream population and the rise of the so called ‘mobile only population’ (ACMA) provide support for this new subject and service paradigm and are often cited as the rationale for digital service reform (APSMR). Media convergence feeds into these dynamics: service delivery becomes the new frontier for the merging of previously separate media distribution systems (Dwyer). Letters, customer service centres, face-to-face meetings and web sites, are combined and in some instances replaced, with online and mobile media platforms, accessible from multiple and mobile devices. These changes are not, however, simply the migration of services to a digital medium with little effective change to the service itself. Health and medical services are re-invented through their technological re-assemblage, bringing into play new meanings, practices and negotiations among the state, industry and neoliberal subjects (in the case of problem gambling apps, a new subjectivity, the ‘neoliberal addict’). These new assemblages are as much about bringing forth a new kind of subject and mode of governance, as they are a solution to problem gambling. This figure of the self-treating “gambler addict” can be seen to be a template for, and prototype of, a more generalised and universalised self-governing citizen: one that no longer needs or makes demands on the state but who can help themselves and manage their own harm. Paradoxically, there is the potential for new risks and harms to the very same users that accompanies this shift: their outright exclusion as a result of deprivation from basic and assumed digital access and literacy, the further stigmatisation of gamblers, the elimination of opportunities for proximal support and their exclusion from everyday spaces. References Albarrán-Torres, César. “Gambling-Machines and the Automation of Desire.” Platform: Journal of Media and Communication 5.1 (2013). Australian Communications and Media Authority. “Australians Cut the Cord.” Research Snapshots. Sydney: ACMA (2013) Berry, David. Critical Theory and the Digital. Broadway, New York: Bloomsbury Academic, 2014 Berry, David. 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